'HE  INDIAN  OPERATION 

OF 

COUCHING 

FOR  CATARACT 


R.  H  ELLIOT. 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


MicUl   LowtfJU 


By  the  Same  Author 

SCLERO  •  CORNEAL  TREPHINING  IN 
THE  OPERATIVE  TREATMENT  OF 
GLAUCOMA,  1913.  Second  Edition, 
1914.  George  Pulrnan  and  Sons,  London. 

GLAUCOMA  :  DIGEST  OF  THE  YEAR'S 
LITERATURE.  The  Ophthalmic  Year- 
book, 1913-1916.  Herrick  Book  and  Sta- 
tionery Company,  Denver,  Colorado,  U.S.A. 

GLAUCOMA  :  A  HANDBOOK  FOR  THE 
GENERAL  PRACTITIONER,  1917. 
H.  K.  Lewis  and  Co.  Ltd.,  London. 

GLAUCOMA  :  A  TEXTBOOK  FOR  THE 
STUDENT  OF  OPHTHALMOLOGY. 

(JVoiv  in  the  press.}      H.   K.   Lewis  and  Co. 
Ltd.,  London. 


I  << 


dt: 
S.J5 
=>< 


t: 


THE  INDIAN  OPERATION  OF 

COUCH  I NG 

FOR   CATARACT 


INCORPORATING 


THE  HUNTERIAN  LECTURES 

DELIVERED    BEFORE    THE    ROYAL    COLLEGE    OF    SURGEONS    OF   ENGLAND   ON 
FEBRUARY    ig    AND   21,    1917 


BY 

ROBERT   HENRY    ELLIOT 

M.D.,  B.S.  LOXD.,  Sc.D.  EDIN.,  F.R.C.S.  ENG.,  ETC. 
LIEUT. -COLONEL  I. M.S.  (RETIRED) 

LATE  SUPERINTENDENT  OF  THE  GOVERNMENT  OPHTHALMIC  HOSPITAL,    MADRAS  ; 
LATE  PROFESSOR  OF  OPHTHALMOLOGY,    MEDICAL  COLLEGE,   MADRAS  ;  AXD  LATE  FELLOW 

OF  THE   UNIVERSITY  OF   MADRAS; 

HOXORARY   FELLOW  OF  THE  AMERICAN   ACADEMY  OF  OPHTHALMOLOGY  AXD 
OTOLARYXGOLOGY. 


WITH   45   ILLUSTRATIONS 


PAUL     B.     HOEBER 

67     &     69     EAST    5QTH     STREET 

NEW     YORK 

1918 


Printed  in  England 


CO 

E.  C.  I.  E. 


So 
E.  TREACHER  COLLINS,  ESQ.,  F.R.C.S. 

IN    GRATEFUL  ACKNOWLEDGMENT   OF    THE    ASSISTANCE 

WHICH    HIS    WORK    ON    THE    PATHOLOGY    OF    THE    EYE 

HAS     BEEN     TO     ALL     WHO     DESIRE     TO     ADVANCE     THE 

SCIENCE   OF   OPHTHALMOLOGY 


PREFACE 


IT  is  a  quarter  of  a  century  since  I  first  landed  in  India.  In 
common  with  very  many  other  surgeons,  my  attention  was 
early  attracted  to  the  operation  of  couching  as  performed  by 
its  Indian  exponents,  and  I  was  horrified  to  see  how  bad  the 
majority  of  the  results  were.  It  appeared  to  me  that  the 
outstanding  need  was  for  carefully  compiled  statistics,  in 
order  that  a  fair  judgment  might  be  formed  on  the  subject. 
I  divested  my  mind  of  partisanship  and  bias,  and  sought  every 
opportunity  to  discuss  the  method  and  its  results  with  anyone 
and  everyone  whose  knowledge  was  likely  to  be  of  use  to  me 
in  my  quest,  whether  they  were  laymen  or  surgeons,  Euro- 
peans or  Indians,  officials  or  non-officials.  The  office  of 
Superintendent  of  the  Government  Ophthalmic  Hospital, 
Madras,  afforded  an  unrivalled  field  for  work,  and  the  staff 
of  the  hospital  co-operated  with  me  in  a  manner  which  I  find 
it  impossible  to  acknowledge  suitably.  My  thanks  are 
especially  due  to  Lieutenant  H.  C.  Craggs,  Assistant-Surgeon 
C.  Taylor,  and  Dr.  Ekambaram,  for  the  valuable  help  they 
gave  me.  After  I  left  India,  Captain  W.  C.  Gray  acted  for 
me  as  Superintendent,  and  later  Major  H.  Kirkpatrick  suc- 
ceeded me  permanently.  Both  of  these  officers  most  gen- 
erously placed  the  material  of  the  hospital  still  at  my  disposal, 
and  rendered  me  very  valuable  service  in  the  study  of  my 
subject.  The  great  majority  of  the  microscopic  slides  were 
very  beautifully  prepared  for  me  by  Mr.  W.  Chesterman.  I 
am  also  indebted  to  Mr.  S.  Stephenson  and  Mr.  A.  C.  Hudson 
for  very  kindly  sectioning  some  of  the  globes  for  me.  The 
photographs,  both  macroscopic  and  microscopic,  were  taken 
by  Mrs.  Elliot,  without  whose  help  I  could  not  have  written 
the  book.  Mr.  E.  Treacher  Collins  has  generously  given  me 
advice  and  assistance  of  the  greatest  value  in  the  study  of 
a  number  of  the  preparations,  and  I  have  acted  freely  on 

vii 


viii  PREFACE 

the  suggestions  he  has  been  good  enough  to  make.  I  desire 
to  express  to  the  Council  of  the  Royal  College  of  Surgeons  of 
England  my  acknowledgment  of  the  honour  they  conferred 
on  me  by  electing  me  to  a  Hunterian  Professorship  of  the 
College.  By  the  kindness  of  the  authorities  concerned,  I 
have  been  enabled  to  include  in  this  book  articles  which  have 
appeared  in  the  Lancet,  in  the  Ophthalmic  Record,  and  in  the 
Proceedings  of  the  Ophthalmological  Society  of  the  United 
Kingdom. 

The  collection  of  fifty-four  eyeballs,  on  which  the  work  for 
my  Hunterian  Lectures  was  founded,  I  have  had  the  honour  to 
present  to  the  Museum  of  the  Royal  College  of  Surgeons. 
I  think  I  am  justified  in  claiming  that  it  is  unrivalled,  and 
likely  to  remain  so.  At  the  suggestion  of  Sir  John  Bland- 
Sutton,  I  have  endeavoured  so  to  write  the  chapter  on  patho- 
logy that  it  may  furnish  a  guide  to  any  who  care  to  study  the 
subject  within  the  walls  of  that  museum.  At  the  same  time, 
I  have  striven  to  make  it  readable  and  of  interest  to  those 
who  have  no  such  opportunity.  In  this  the  photographs 
have  greatly  helped  me. 

As  I  have  already  said,  I  have  given  nearly  a  quarter  of 
a  century's  intermittent  work  to  elucidate  these  problems, 
which  I  felt  were  of  wide  interest,  not  merely  to  India  or  to 
the  East  alone,  but  to  the  whole  civilized  world.  During  the 
last  two  years  I  have  devoted  a  very  large  proportion  of  my 
spare  time  continuously  to  the  subject,  but  it  is  so  immense 
and  so  far-reaching  that  I  feel  I  have  left  much  unfinished. 
On  every  hand  fresh  problems  open  up,  till  there  seems  no 
limit  to  what  might  be  done,  given  time  and  opportunity. 
This  operation  of  couching,  so  old  that  its  origin  is  lost  in  the 
dim  mists  of  antiquity,  has  still  much  that  is  new  to  be  learnt 
for  the  seeking.  There  are  many  of  the  younger  surgeons 
in  the  East  who  could  carry  the  work  much  farther  if  they 
would,  and  who  would  be  a  hundred-fold  repaid  if  they  did. 
Will  they  ? 


ROBERT  HENRY  ELLIOT. 


54,  WELBECK  STREET, 

CAVENDISH  SQUARE,  W., 


CONTENTS 

CHAPTER  PAGE 

I.    THE  HISTORY  OF  COUCHING       -  I 

II.    THE  TECHNIQUE  OF  THE  OPERATION     -  14 

III.  THE  INDIAN   COUCHER  AND  HIS  HABITS  -          K) 

IV.  STATISTICAL       -  25 
V.    THE    PATHOLOGICAL   ANATOMY    OF   COUCHED   EYES  -         35 

VI.    DIAGNOSIS           -  -         77 

VII.    CLINICAL  -         85 

INDEX  -         92 


LIST   OF    ILLUSTRATIONS 

FIGS,  i  AND  2.  BARTISCH'S  OPERATION  (PLATE  i.)  -  -  Frontispiece 

FIG.  PAGE 

3.  THE  STAGES  OF  DEPRESSION     -  8 

4.  THE  STAGES  OF  RECLINATION    -  -  8 

5.  SCARPA'S  NEEDLE  AS  USED  BY  MACKENZIE      -  8 

6.  THE  ANTERIOR  METHOD  OF  COUCHING  -  14 

7.  THE  POSTERIOR  METHOD  OF  COUCHING  -  14 

8.  GROUP  SHOWING  THE  INDIAN  OPERATION  OF  COUCHING  -  1 5 

9.  THE  INSTRUMENTS  USED  IN  COUCHING  IN  THE  SOUTH  OF  INDIA  17 

PLATE      II.  PACING 

PAGE 

10.  LENS   DISLOCATED   BETWEEN   CILIARY   BODY  AND   SCLERA 

11.  NUCLEUS      OF       CATARACT     FREELY     MOVABLE     BETWEEN     THE 

AQUEOUS  AND  VITREOUS  CHAMBERS 

12.  LENS  IMPACTED  IN  ANGLE  OF  ANTERIOR  CHAMBER 

13.  CAPSULE   OF   MORGAGNIAN    CATARACT   IMPACTED    IN    ANGLE   OF    f   38 

ANTERIOR  CHAMBER 

14.  LENS   FLOATING  FREE  IN  VITREOUS   CHAMBER  - 

15.  LENS     LIGHTLY     IMPRISONED     IN     EXUDATE     INTO     VITREOUS 

CAVITY 

PLATE    III. 

16.  ABUNDANT  EXUDATE  INTO  VITREOUS  CAVITY   - 

17.  LENS  FIRMLY  FIXED   BY  ORGANIZED  EXUDATE 

1 8.  LENS    FIRMLY    FIXED    BY    ORGANIZED    EXUDATE,    BUT    IN    UN- 

USUAL POSITION 

19.  TOTAL  DETACHMENT  OF  RETINA,  WITH  CYST  FORMATION 

20.  RECLINED   LENS    LYING   IN    FRONT    OF  THE   HYALOID   BODY 

21.  RECLINED   LENS   LYING  IN   FRONT   OF  THE  HYALOID   BODY 

xi 


xii  LIST  OF  ILLUSTRATIONS 

PLATE     IV.  FACING 

FIG.  PAGE 

22.    LENS  DISLOCATED  BEHIND  RETINA 


48 


54 


23.  FISTULA  OF  THE  CORNEA 

24.  CAPSULO-CORNEAL  SYNECHIA   - 

25.  RETINO-CORNEAL  SYNECHIA 

26.  SCLERAL  FISTULA 

27.  ,,  „  (MAGNIFIED) 

PLATE  V. 

28.  INJURIES  TO  UVEAL  TRACT 

29.  FOREIGN  BODY  (TIP  OF  COPPER  PROBE)   IMBEDDED  IN  THE  EYE 

30.  TRAUMATIC  DETACHMENT  OF  RETINA  AND   CHOROID 

31.  WHOLE-SECTION  OF  FIG.    1 9 

32.  PART    OF    THE    ABOVE    MAGNIFIED    TO    SHOW    LENS    IMBEDDED 

IN  INFLAMMATORY  EXUDATE 

33.  PHAGOCYTOSIS   - 

PLATE  VI. 

34.  L'lRIS  BOMBE  AND  RETINAL  CYST 

35.  MATTING  OF  STRUCTURES  OF  THE  EYE  DUE  TO  INFLAMMATION 
36. 

(HIGHER  MAGNIFICATION)     - 
37-  UNUSUAL    APPEARANCE    OF    EXUDATE    INTO    THE  VITREOUS 

CAVITY 

38.    INFLAMED  OPTIC  NERVE  HEAD 
39-    ADVANCED  ORGANIZATION  OF  VITREOUS  EXUDATE 

PLATE   VII. 

40.  HEMORRHAGE  INTO  VITREOUS   CAVITY 

41.  PROLIFERATIVE  DOT  IN  RETINA 

42.  COLLECTION   OF  LEUCOCYTES  ON  SURFACE  OF  RETINA 


43.  SMALL  CYSTS   IN   RETINA 

44.  WHOLE-SECTION     OF      FIG.     34,     SHOWING     L'lRIS     BOMB^     AND 

RETINAL   CYST 

45.  ADHERENT  LENS   PRESSING  ON  IRIS   BASE 


72 


COUCHING    FOR    CATARACT 

CHAPTER  I 

THE  HISTORY  OF  COUCHING 

THE  operation  of  couching  for  cataract  is  one  of  the  most 
ancient  procedures  known  to  surgery,  the  earliest  description 
of  the  method  being  that  given  by  Celsus,  a  contemporary 
of  Christ's.  The  first  historical  mention  of  ophthalmic  sur- 
geons was  in  Alexandria,  at  the  time  when  medicine  and 
surgery  underwent  separation  from  each  other  in  that  great 
and  flourishing  city,  nearly  three  centuries  before  the  dawn 
of  the  Christian  era,  and  Galen  states  that  some  of  these  sur- 
geons devoted  themselves  exclusively  to  operating  on  cataracts. 
Celsus  speaks  of  the  writings  of  a  famous  Alexandrian  surgeon, 
named  Philoxenes,  who  lived  270  years  before  Christ,  and 
from  whom  he  apparently  derived  much  of  his  lore.  These 
writings  have  unfortunately  been  lost,  thus  yielding  to 
Celsus  the  proud  position  of  being  the  first  author  whose 
description  of  the  operation  has  come  down  to  modern  times. 
Sprengel  is  of  the  opinion  that  couching  was  not  only  known 
long  before  the  time  of  Celsus,  but  also  that  the  technique 
of  the  operation,  even  at  that  distant  era,  varied  widely  in 
the  hands  of  its  different  exponents.  Of  the  correctness  of 
this  view  there  can  be  little  doubt.  Sir  John  Bland-Sutton 
has  recently  published  a  most  interesting  memoir  on  the 
recovery  of  the  sight  of  Tobit  at  the  hands  of  his  son  Tobias, 
as  described  in  the  Apocrypha,  and  has  included  in  it  a  copy 
of  Rembrandt's  picture  of  the  famous  operation.  Whether 
the  displacement  of  the  lens  was  due  to  the  rubbing  employed 
or  to  more  definite  operative  measures  must  be  left  to  specu- 
lation, but,  in  considering  this  point,  it  is  worth  remembering 
that  the  Eastern  coucher  of  to-day  hides  the  fact  that  he  is 
performing  an  operation  under  the  cloak  of  the  application 


2  COUCHING  FOR  CATARACT 

of  a  medicinal  paste.  Nor  must  we  forget  that  the  anointing 
of  the  eyes  of  the  blind  with  clay  played  a  leading  part  in  one 
at  least  of  the  New  Testament  miracles,  and  is  suggested  in 
a  second.  It  is  to  be  remembered  that  the  Founder  of  Chris- 
tianity took  His  examples  from,  and  moulded  His  teachings 
by  the  aid  of  things  familiar  to  the  people  in  their  everyday 
life.  The  influence  of  the  Oriental  on  the  introduction  of 
couching  to  the  Western  surgeon  is  shown  by  the  repeated 
references  in  the  history  of  the  subject  to  Eastern  exponents 
of  the  procedure.  Thus,  Razes  speaks  of  the  work  of  an 
Indian  named  Tabri,  and  Avicenna,  himself  an  Arabian, 
describes  at  length  the  instruments  and  technique  of  the  Arab 
cataract  operators.  Abu  El  Kasim's  name  proclaims  his 
Arab  parentage,  despite  the  fact  that  he  is  spoken  of  as  a 
Spanish  surgeon,  and  the  conviction  is  deepened  by  the  fact 
that  he  spoke  of  the  Arabs  in  Spain  as  confining  themselves 
to  couching  in  the  treatment  of  cataract,  showing  he  was  in 
intimate  touch  with  them.  Nor  must  we  forget  to  mention 
the  work  of  Haly  Abbas,  and  of  his  distinguished  son  Jesu 
Haly. 

When  we  endeavour  to  ascertain  the  probable  date  of  the 
first  invention  of  the  operation  in  the  East,  the  fog  of  uncer- 
tainty closes  down  over  us,  obliterates  all  trace  of  our  quest, 
and  drives  us  to  fall  back  on  inference.  Those  who  have 
spent  their  lives  in  an  Eastern  land  know  the  unbending  force 
of  tradition,  the  hereditary  character  of  occupations,  and  the 
intense  conservatism  of  Oriental  peoples.  All  these  influences 
are  against  change  of  any  kind,  and  greatly  retard  the  spread 
of  new  ideas.  When  we  consider  an  operation  like  couching, 
which  is  well  known  over  the  whole  of  the  East,  and  which 
meets  in  the  simplest  manner  an  age-long  need,  felt  in  every 
village  of  a  tropical  or  subtropical  country,  it  is  not  difficult 
to  believe  that  the  procedure  may  have  been  one  of  the  early 
fruits  of  advancing  civilisation,  far  away  back  in  Babylon  the 
Great,  or  even  earlier  still  in  the  home  of  the  Pyramids,  tens 
of  centuries  before  the  dawn  of  the  Christian  era.  From 
these  attractive  speculations  we  must  return  to  weigh  the 
literature  of  our  subject,  of  which  the  foundation  was  so  well 
and  truly  laid  by  the  great  Celsus.  His  description  of  the 
technique  he  employed  is  as  follows: 


THE  HISTORY  OF  COUCHING  3 

"  Before  the  operation  the  patient  must  use  a  spare  diet. . . . 
After  this  preparation  he  must  sit  in  a  light  place,  in  a  seat 
facing  the  light,  and  the  physician  must  sit  opposite  the 
patient  on  a  seat  a  little  higher;  an  assistant  behind  taking 
hold  of  the  patient's  head,  and  keeping  it  immovable,  for  the 
sight  may  be  lost  for  ever  by  a  slight  motion.  Moreover, 
the  eye  itself  must  be  rendered  more  fixed  by  laying  wool 
upon  the  other  and  tying  it  on.  The  operation  must  be 
performed  on  the  left  eye  by  the  right  hand,  and  on  the  right 
by  the  left  hand.  Then  the  needle,  sharp-pointed,  but  by 
no  means  too  slender,  is  to  be  applied  and  must  be  thrust 
in,  but  in  a  straight  direction,  through  the  two  coats,  in  the 
middle  part  betwixt  the  black  of  the  eye  and  the  external 
angle  opposite  to  the  middle  of  the  cataract.  .  .  .  The  needle 
must  be  turned  upon  the  cataract  and  gently  moved  up  and 
down  there,  and  by  degrees  work  the  cataract  downward 
below  the  pupil;  when  it  has  passed  the  pupil,  it  must  be 
pressed  down  with  a  considerable  force  that  it  may  settle  in 
the  inferior  part." 

Further  details  follow.  To  put  the  matter  shortly  in 
modern  terminology,  Celsus  introduced  a  needle  through  the 
sclera  and  choroid  into  the  vitreous  chamber,  and  depressed 
the  lens  from  behind,  after  first  rupturing  its  posterior  capsule 
by  vertical  strokes  made  with  the  point  of  the  instrument. 
As  already  mentioned,  Galen  (born  A.D.  131)  states  that  there 
were  both  in  Alexandria  and  in  Rome  surgeons  who  con- 
fined themselves  to  operating  upon  cataract.  Apparently 
he  also  described  his  own  procedure,  for  some  five  centuries 
later  Paulus  yEgineta  (circa  A.D.  630),  in  detailing  his  tech- 
nique, gave  Galen  the  credit  for  it.  There  is  practically  no 
difference  between  the  method  they  both  employed  and  that 
originally  laid  down  by  Celsus.  A  point  of  real  interest  in 
this  connection  is  that  the  description  of  the  operation 
given  by  Paulus  is  practically  the  only  one  extant  from 
the  pen  of  a  Greek  author,  though  not  a  few  of  them  men- 
tion couching  and  advocate  it. 

For  the  next  landmark  in  the  study  of  the  subject  we  have 
to  pass  over  three  and  a  half  centuries,  till  we  come  to  the 
writings  of  Avicenna  (circa  A.D.  980),  in  which  we  find  in- 
troduced a  new  feature  in  the  technique ;  for  he  mentions 


that  the  Arab  surgeons  used  two  instruments  for  couching — 
viz.,  a  two-edged  lancet  with  which  they  made  a  corneal 
incision,  and  a  needle  with  which  they  depressed  the  cataract, 
after  introducing  it  through  the  incision  thus  made.  In 
this  needle  there  was  an  eye  near  the  point,  through  which 
a  thread  was  inserted.  According  to  Avicenna,  the  object 
of  this  was  to  help  depress  the  lens,  but  it  seems  at  least 
possible  that  the  thread  passed  through  this  eye  was  wound 
round  the  instrument,  and  so  served  as  a  stop,  similar  to 
that  used  by  the  Indian  coucher  to-day.  In  any  case  the 
description  is  of  great  interest,  linking  as  it  does  the 
Mahomedan  operator  of  the  twentieth  century  with  his  pre- 
decessor of  the  tenth.  The  famous  Spanish  surgeon  Abu  El 
Kasim  adopted  exactly  the  same  technique  for  couching  as 
that  we  have  just  described.  This,  as  has  already  been 
suggested,  is  not  in  the  least  remarkable,  for  his  name  bespeaks 
his  Arab  descent. 

The  next  description  of  the  operation,  which  claims  our 
interest,  is  that  by  Benvenuto  (Benevenutus  Hyerosolimi- 
tamus),  who  flourished  in  the  twelfth  century.  The  quaint 
blending  of  religion  and  science,  which  it  reveals,  makes  it 
very  attractive  reading :  "  Towards  the  third  hour,  the  patient 
having  fasted,  thou  shouldst  make  him  sit  astride  of  an  or- 
dinary chair,  and  thou  shouldst  sit  before  him  in  the  same 
way.  Keep  the  good  eye  of  the  patient  shut,  and  begin  to 
operate  on  the  bad  eye,  in  the  name  of  Jesus  Christ.  With 
one  hand  raise  the  upper  lid,  and  with  the  other  hold  the 
silver  needle,  and  place  it  in  the  part  where  the  small  angle 
of  the  eye  is.  Perforate  the  same  covering  of  the  eye,  turning 
the  instrument  round  and  round  between  the  fingers,  till  thou 
hast  touched  with  the  point  of  the  needle  that  putrid  water 
which  the  Arabs  and  Saracens  called  Mesoret,  and  which  we 
call  cataract.  Then  beginning  from  the  upper  part,  remove 
it  from  the  place  where  it  is  before  the  pupil,  and  make  it 
come  down  in  front,  and  then  hold  it  for  as  long  as  it  takes 
to  say  four  or  five  paternosters.  After,  remove  the  needle 
gently  from  the  top  part.  If  it  happens  that  the  cataract  reas- 
cends,  reduce  it  towards  the  lower  angle,  and  when  you  have  in- 
troduced the  needle  into  the  eye,  do  not  draw  it  out  unless  the 
cataract  be  situated  in  the  place  described  above ;  then  gently 


THE  HISTORY  OF  COUCHING  5 

extract  the  needle  in  the  same  way  as  you  put  it  in,  turning 
it  about  between  the  fingers.     The  needle  being  extracted, 
keep  the  eye  closed  and  make  the  patient  lie  flat  on  a  bed, 
keeping  him  in  the  dark  with  his  eyes  shut,  so  that  he  does 
not  see  the  light  or  move  for  eight  days,  during  which  time 
put  white  of  egg  on  twice  a  day  and  twice  during  the  night." 
Passing  over  four  centuries,  we  come  to  an  even  more 
interesting   description   of   the   operation   from   the   pen   of 
Bartisch  of  Dresden :  "  The  day  being  decided  upon,  on  which 
the  operation  is  to  be  performed,  the  doctor  who  is  obliged 
to,  or  who  wishes  to  do  it,  must  abstain  from  wine  for  two  days 
beforehand.     The  patient  must  also  fast  the  same  day,  and 
must  neither  eat  much  nor  little  till  an  hour  after  the  opera- 
tion.    Given   the   aforesaid   conditions,   try   and   procure   a 
well-lighted  room,  in  which  the  patient  may  have  everything 
necessary  for  going  to  bed  and  remaining  there,  as  he  ought 
not  to  be  taken  to  any  place  far  off;  the  nearer  to  bed  the 
better.     Set  thyself  on  a  bench  in  the  light  and  turn  thy 
back  to  the  window.     The  patient  may  be  seated  on  a  chair, 
a  stool,  or  on  a  box,  before  thee  and  near  to  thee ;  in  any  case 
he  is  to  be  seated  lower  than  thyself.     His  legs  between  thine 
and  his  hands  on  thy  thighs.     A  servant  stands  behind  to 
hold  the  patient's  head.     The  servant  should  bend  a  little, 
so  that  the  patient  may  rest  his  head  against  him  (Fig.  i). 
When  the  patient  is  blind  of  one  eye  only,  the  other  eye  should 
be  bandaged  with  a  cloth  and  a  pad  so  that  he  cannot  see. 
Then  take  the  instrument  or  the  needle  in  one  hand,  so  that 
the  right  hand  will  be  for  the  left  eye,  and  vice  versa.     With 
the  other  hand  separate  with  great  care  the  upper  lid  from 
the  lower,  using  the  thumb  and  the  first  finger,  so  that  thou 
canst  see  how  to  direct  the  needle  into  the  eye.     When  thou 
wishest  to  introduce  the  needle,  the  eye  must  be  turned 
towards  the  light  and  looking  straight  at  thee ;  also,  I  should 
make  the  patient  turn  his  eye  a  little  towards  his  nose,  so 
that  thou  canst  use  the  instrument  better  and  that  thou  wilt 
not  injure  the  small  veins  of  the  eye,  but  respect  them.     Direct 
the  needle  straight  and  with  attention  over  the  membrane 
called  the  conjunctiva,  straight  towards  the  pupil  and  uvea, 
at  the  distance  of  two  blades  of  a  knife  from  the  membrane 
called  cornea  or  from  the  grey  that  is  in  the  eye.     Hold  the 


6  COUCHING  FOR  CATARACT 

needle  quite  straight,  hold  it  steady  so  that  it  will  not  deviate 
or  slip.  Hold  the  needle  and  press  it,  and  turn  it  with  the 
fingers  in  the  eye  with  great  gentleness,  according  to  the 
instructions  you  may  gather  from  the  figure,  which  shows 
an  eye  in  which  the  cataract  has  been  taken  away,  while  the 
other  eye  has  not  been  touched  (Fig.  2).  Hold  the  needle 
firmly  while  turning  it  round,  and  be  careful  always  to  have 
the  point  towards  the  middle  of  the  eye,  that  it  almost  touches 
the  pupil  and  the  uvea;  and  not  to  oscillate  by  any  chance 
towards  one  side.  When  thou  feelest  that  the  needle  has 
penetrated  into  the  eye,  that  it  almost  touches  the  pupil  and 
the  uvea,  and  when  thou  hast  proved  to  be  really  in  the  eye, 
hold  the  needle  securely  and  move  it,  letting  it  slip  back- 
wards and  forwards  towards  the  pupil  till  thou  art  certain 
of  being  in  the  substance  of  the  cataract,  which  thou 
canst  easily  be  sure  of  by  the  movement  of  the  cataract 
material.  When  thou  hast  remarked  that,  lower  it  carefully 
and  gently  and  slowly,  so  as  not  to  disturb  the  cataract ;  but 
try  and  free  the  matter  entirely  from  the  pupil  and  from  the 
uvea  with  care,  and  keep  it  intact.  Press  the  said  matter 
with  the  needle  under  it,  with  the  greatest  care,  and  when 
thou  perceivest  that  it  is  altogether  free  and  loose,  draw  and 
direct  the  needle,  with  the  matter  behind  it,  upwards,  and 
then  pass  it  well  downwards,  behind  the  thin  retina  and  the 
aranea  of  the  eye;  and  take  care  that  it  remains  there.  .  .  . 
This  is  the  recognised  instruction,  research,  and  indication 
of  the  means  of  operating,  of  pricking  the  cataract,  or  of  the 
manner  in  which  such  an  operation  ought  to  be  initiated  and 
conducted.  But  no  one  ought  to  undertake  such  an  opera- 
tion unless  he  has  learnt  much  and  seen  much,  and  unless  he 
is  fundamentally  taught  by  intelligent  doctors.  Unless  he 
is  so,  it  is  not  well  to  operate.  And  it  is  not  wise  to  trust  to 
any  of  the  brotherhood  who  happen  to  be  dressed  in  velvet  or 
silk,  and  who  boast  of  being  great  oculists,  and  are  capable  of 
curing  the  blind  from  cataract.  Certainly  these  can  make 
holes  in  the  eyes,  but  I  do  not  know  how  they  can  succeed. ' ' 

The  knowledge  which  the  Greeks  and  the  Arabs  possessed, 
before  and  after  the  dawn  of  the  Christian  era,  on  the  subject 
of  the  pathology  and  treatment  of  cataract,  appears  to  have 
been  largely  forgotten  during  the  Middle  Ages.  It  would 


THE  HISTORY  OF  COUCHING  ^ 

seem  that  both  couching  and  extraction  fell  into  disuse,  and 
that  the  surgical  treatment  of  cataract  was  left  for  centuries 
in  the  hands  of  wandering  charlatans,  whose  ways  brought 
much  discredit  upon  it.  Towards  the  close  of  the  seventeenth 
century,  Pierre  Brisseau,  a  doctor  of  Tournay,  revived  the 
operation,  inventing  a  needle  of  his  own  for  the  purpose. 
His  advocacy  of  the  method  aroused  bitter  controversy,  but 
it  was  undoubtedly  the  best  operation  in  the  field  until  the 
famous  French  surgeon  Daviel  performed  his  first  extraction 
in  1745,  and  thus  sounded  the  death-knell  of  a  procedure 
which  had  held  the  pride  of  place  in  European  surgery  for  over 
seventeen  centuries.  It  was,  however,  many  years  before 
couching  was  definitely  abandoned  in  favour  of  extraction. 
Indeed,  the  author  has  recently  had  the  privilege  of  discussing 
this  subject  with  a  distinguished  surgeon,  who  can  remember 
the  time  when  depression  was  still  a  recognised  method  of 
operating  in  London.  It  is  a  great  mistake  to  suppose  that 
Daviel  was  the  first  to  endeavour  to  extract  a  cataract,  for 
both  extraction  and  suction  of  cataracts  have  their  roots  far 
back  in  history.  Indeed,  Antyllus  described  his  method  of 
extraction  at  the  close  of  the  first  century  of  the  Christian  era, 
and  there  are  numerous  other  references  to  it  in  early  literature. 
What  Daviel  did  was  to  adopt  a  technique  which  gave  a  reason- 
able prospect  of  success. 

The  introduction  of  reclination,  as  opposed  to  depression, 
by  Willburg  in  a  Nuremberg  thesis,  dated  1785,  gave  a  fresh 
lease  of  life  to  couching  in  its  dying  struggle  with  the  opera- 
tion which  was  destined  to  supersede  it.  England,  France, 
Sweden,  Germany,  and  other  countries,  joined  vigorously  in 
the  discussion,  and  amongst  the  powerful  advocates  of  couching 
were  ranked  Percival  Pott  and  William  Hay  of  London, 
Cusson  of  Montpellier,  and  Scarpa  of  Pa  via,  whilst  Benjamin 
Bell  practised  both  couching  and  extraction.  The  admirable 
treatise  by  James  Ware  on  cataract  (1812)  was  all  but  a 
death-blow  for  Celsus's  operation.  The  newer  procedure 
was  then  well  in  the  ascendant,  and  only  needed  time  to  com- 
pletely strangle  its  rival.  Notwithstanding  this,  it  was  left 
to  Mackenzie,  so  late  as  1854  (fourth  edition),  to  give  the  most 
complete  and  interesting  description  of  couching  to  be  found  in 
literature.  He  distinguishes  sharply  between  the  operations 


8 


COUCHING  FOR  CATARACT 


of  depression  and  reclination.  In  depression,  the  lens  is  pushed 
directly  below  the  level  of  the  pupil,  being  made  to  follow  the 
curvature  of  the  eye,  to  sweep  over  the  corpus  ciliare,  until 
it  comes  to  rest  on  the  lower  curve  of  the  eyeball,  with  its 
anterior  surface  directed  forward  and  downward  (Fig.  3). 
In  reclination,  the  lens  is  made  to  turn  over  towards  the  bottom 


FIG.  3. — DEPRESSION.  FIG.  4. — RECLINATION. 

The  above  two  figures  illustrate  the  path  taken  by  the  cataract  during 
the  operation.     (Mackenzie.) 

of  the  vitreous  chamber  in  such  a  way  that  what  was  formerly 
its  anterior  surface  now  comes  to  look  upward,  and  what  was 
its  upper  edge  is  turned  to  the  rear.  The  whole  lens  is  swung 
backward  as  if  on  a  hinge,  composed  of  the  lower  fibres  of  its 
suspensory^  ligament,  which  still  remain  unbroken  (Fig.  4). 
He  divides  the~operation  of  couching  into  four  stages,  in  only 
the  last  of  which  reclination  differs  from  depression.  These  are : 
(i)  the  pushing~of  a  special  needle  (Fig.  5)  through  the  coats 


FIG.  5. 

of  the  eye  at  a  distance  of  £  inch  behind  the  temporal  edge  of 
the  cornea,  and  to  a  depth  of  ^  inch;  (2)  the  laceration  of  the 
posterior  capsule  of  the  lens  by  vertical  movements  of  the  point 
of  the  needle,  to  prepare  an  aperture  for  the  passage  of  the 
lens;  (3)  the  passing  of  the  needle  into  the  anterior  chamber 
around  the  edge  of  the  lens,  and  the  laceration  of  the  anterior 
capsule  by  vertical  strokes ;  (40)  to  depress  the  lens,  the  point 
of  the  needle  is  carried  over  its  upper  edge,  and  the  handle  is 


THE  HISTORY  OF  COUCHING  9 

raised  a  little  above  the  horizontal,  thereby  correspondingly 
lowering  the  point,  which  forces  the  cataract  downward  out 
of  sight  behind  the  pupil:  the  needle  is  then  withdrawn  by 
rotation;  (46)  to  effect  reclination,  the  needle-point  is  raised 
not  more  than  TV  inch  above  the  transverse  diameter  of  the 
lens:  its  concave  surface  is  pressed  against  the  cataract, 
which  is  reclined  by  moving  the  handle  of  the  instrument 
upward  and  forward,  thereby  causing  its  point  to  pass  down- 
ward and  backward.  The  cataract  is  thus  made  to  fall  over 
into  the  vitreous  humour,  and  is  then  pressed  downward, 
backward,  and  a  little  outward.  Mackenzie  adds  many  interest- 
ing details  as  to  the  modifications  of  the  operation,  according 
to  the  variety  of  the  cataract  to  be  dealt  with,  and  as  to  the 
after-treatment  and  complications  met  with. 

We  come  now  to  a  very  interesting  phase  in  the  study  of 
the  operation  of  couching.  We  have  shown  reason  to  believe 
that,  like  many  another  valued  heritage  of  the  West,  it  was 
brought  there  originally  by  Wise  Men  of  the  East.  For  more 
than  eighteen  centuries  it  remained  a  treasured  possession  of 
surgery,  only  to  yield  its  ground  before  the  fierce  competition 
of  a  method  better  able  to  survive  the  stern  test  of  experience. 
Slowly  but  surely  its  decadence  banished  it  from  modern 
scientific  European  literature,  and  then,  strangely  enough, 
the  advent  of  Listerism  fanned  the  dying  flame  of  interest 
in  the  method ;  but  this  time  in  the  East,  and  not  in  the  West. 
From  the  East  it  had  sprung  to  find  a  home  in  the  W'est,  and 
in  the  East,  at  the  hand  of  Western  surgeons,  its  last,  and  by 
no  means  least,  interesting  chapter  is  in  the  course  of  being 
written.  A  review  of  the  more  recent  literature  on  the  sub- 
ject will  establish  this  contention,  and  will  show  how  large  a 
share  the  officers  of  the  Indian  Medical  Service  have  taken  in 
the  settlement  of  a  question  which,  apart  from  its  scientific 
value,  has  important  social  and  even  political  bearings. 

After  a  brief  visit  to  India,  Hirschberg,  in  1894,  published 
an  article  on  couching,  in  the  course  of  which  he  spoke  favour- 
ably of  the  results  of  the  operation.  He  was,  unfortunately, 
handicapped  by  his  ignorance  of  the  natives  of  India  and 
of  their  ways  and  customs,  with  the  result  that  his  views  on 
the  subject  are  of  comparatively  little  interest  to  us.  In 
the  following  year  Captain  H.  E.  Drake-Brockman  described  the 


io  COUCHING  FOR  CATARACT 

operation  of  couching  as  explained  to  him  by  one  of  its  Indian 
exponents.  The  latter  pierced  the  sclerotic  with  a  small 
lancet  in  the  lower  outer  quadrant  close  to  the  cornea,  and 
then  introduced  a  copper  needle;  "  a  series  of  motions  of  the 
hand  are  made  from  the  position  on  first  introduction  of  the 
needle  to  a  point  corresponding  to  it  in  the  upper  section  of 
the  outer  diameter  of  the  eyeball."  The  depression  of  the 
lens  appears  to  have  taken  place  next,  but  the  description  is 
throughout  somewhat  vague.  Presumably  the  operation 
was  the  same  as  that  described  by  Ekambaram,  but  the 
coucher  does  not  seem  to  have  been  able  to  make  the  steps  of 
the  procedure  as  clear  as  that  surgeon  has  done. 

Henry  Power,  in  the  British  Medical  Journal  (October, 
1901),  entered  a  plea  for  the  occasional  performance  of  the 
operation  of  depression  in  cases  of  cataract.  His  experience 
went  far  enough  back  to  enable  him  to  remember  the  time, 
not  only  when  he  had  seen  surgeons  of  repute  employ  this 
method,  but  when  he  had  himself  imitated  the  example  thus 
set.  His  own  practice  had  been  to  attack  the  cataract,  via 
the  sclerotic,  through  the  posterior  capsule.  He  framed  a 
number  of  indications  which  to  his  mind  justified  the  occasional 
performance  of  couching.  It  is  safe  to  say  that  very  few  of 
these  would  be  seriously  entertained  by  surgeons  to-day.  The 
most  interesting  point  he  made  was  in  connection  with  Himly, 
in  whose  work,  published  in  1843,  the  statement  occurred 
that  "  severe  inflammation  rarely  followed  reclination,  and 
when  it  did  it  often  cleared  up  without  leaving  any  bad  con- 
sequences." A  doubt  as  to  the  reliability  of  Himly 's  state- 
ments is  suggested  by  his  claim  that  he  had  only  two  failures 
in  fifty  cases,  one  of  these  not  being  attributable  to  the  opera- 
tion. This  is  so  much  at  variance  with  the  experience  of 
others  as  to  make  one  sceptical  about  accepting  any  of  his 
assertions  without  some  reservation. 

The  next  paper  of  value  that  we  come  to  is  by  Maynard 
(1903).  In  this  he  analysed  sixty-three  cases  of  couching, 
which  he  had  met  with  in  Indian  practice,  and  recorded  the 
anatomical  examination  by  Parsons  of  a  couched  eye  sent  home 
for  the  purpose.  The  same  year  saw  the  appearance  of  a 
paper  by  Albertotti  of  Medina,  in  which  that  writer  some- 
what fanatically  and  unconvincingly  advocated  a  return  to 


THE  HISTORY  OF  COUCHING  n 

couching,  with  the  use  of  a  corneal  puncture  and  with  the  em- 
ployment of  special  instruments  for  the  purpose.  A  year 
later  he  was  followed  along  the  same  lines  by  Basso  of  Genoa, 
whilst  Quartillera  published  a  paper  whose  recommendations 
were  very  similar  to  those  made  by  Henry  Power.  In  1905, 
Major  Henry  Smith  of  Jullundur,  in  a  very  outspoken  article 
in  the  Indian  Medical  Gazette,  expressed  the  opinion  "  that 
lens  couching  at  the  present  time  is  an  operation  which  should 
not  be  practised  outside  the  ranks  of  charlatans,"  and  added 
that  "it  is  no  easy  matter  to  completely  dislocate  the  lens, 
and  in  my  observation  the  partial  dislocation  is  more  frequent 
than  the  complete  in  the  hands  of  adepts  of  the  art."  In 
reply  to  this  paper,  Maynard  reaffirmed  his  belief  that  couching 
is  "  justifiable  under  certain  conditions."  The  editor  of  the 
Indian  Medical  Gazette  invited  further  discussion  of  the  sub- 
ject, and  in  accordance  with  this  request  the  writer  published 
his  statistics  based  on  125  cases  of  couching,  carefully  recorded 
on  printed  schedules.  In  the  course  of  that  paper  he  voiced 
his  strong  opposition  to  the  adoption  of  the  Indian  operation, 
or  of  any  modification  of  it,  in  the  hands  of  surgeons  who  enjoy 
the  unique  opportunity  of  obtaining  manipulative  skill  granted 
to  those  who  work  in  India.  A  former  pupil  of  his,  Dr.  Ekam- 
baram,  studied  the  ways  of  the  Indian  coucher  at  first-hand, 
and  gave  the  results  of  his  experience  in  one  of  the  most  valu- 
able contributions  to  the  subject  yet  made.  This  was  in  1910. 
Two  years  later  the  writer  was  able  to  review  the  statistics 
of  550  consecutive  cases  of  couching,  all  of  which  had  been 
carefully  noted.  Still  more  cases  accumulated  before  he  left 
India,  and  by  the  kindness  of  Major  Kirkpatrick,  the  total 
under  review  has  now  reached  780. 

The  examination  by  J.  H.  Parsons  of  a  couched  eye  has 
already  been  mentioned.  In  1913,  A.  C.  Hudson  sectioned  and 
described  a  similar  specimen  sent  him  from  India  by  the 
writer.  The  only  previous  published  records  of  the  same  kind 
are  from  the  pen  of  E.  Treacher  Collins,  and  refer  to  four  speci- 
mens of  couched  eyes  in  the  Museum  of  the  Royal  London 
Ophthalmic  Hospital.  Major  H.  Kirkpatrick  has  recently 
examined  several  more  cases  in  Madras,  and  has  kindly  com- 
municated some  of  the  more  interesting  of  his  findings  to  the 
writer.  Communications,  that  have  been  made  from  time  to 


12         COUCHING  FOR  CATARACT 

time  before  meetings  of  ophthalmologists,  show  that  British 
surgeons  of  the  first  rank  are  still  in  favour  of  performing 
couching  under  certain  special  conditions.  A  marked  instance 
of  this  is  to  be  found  in  the  discussion  which  took  place  before 
the  Ophthalmological  Society  of  the  United  Kingdom  on 
February  8,  1906,  following  the  presentation  of  a  case  by 
Holmes  Spicer.  On  that  occasion  Rockliffe  and  Treacher 
Collins  stated  that,  like  Spicer,  they  had  performed  the  opera- 
tion in  exceptional  cases,  and  Devereux  Marshall  and  G.  W. 
Roll  accorded  it  a  modified  support  under  such  conditions. 
The  writer  has  also  learnt  from  personal  communications 
that  other  leading  surgeons  have  taken  a  similar  line.  There 
for  the  present  we  must  leave  the  history  of  this  operation, 
whose  origin  is  lost  in  the  dim  mists  of  antiquity,  and  whose 
chequered  career  forms  one  of  the  most  interesting  pages  in 
the  literature  of  medicine. 


BIBLIOGRAPHY 

ALBERTOTTI,  GIUSEPPE:  Benevenuti  Grassi,  de  oculis  eorumque  aegritudini- 

bus  (reedition  de  1'incunable  de  Ferrare,  1498);  Paris,  1897. 
ALBERTOTTI,  GIUSEPPE:  Depression  of  Cataract,  La  Clinica  Oculistica,  June, 

1903. 
AMERICAN  ENCYCLOPEDIA  and  Dictionary  of  Ophthalmology,  Casey  Wood; 

Chicago,  1916. 

BASSO:  La  Clinica  Oculistica,  January,  1904. 
BLAND-SUTTON,  SIR  JOHN:  On  an  Apocryphal  Miracle,  Middlesex  Hospital 

Journal,  vol.  xx.,  No.  i. 

BRISSEAU:  Traite  de  la  Cataracte  et  du  Glaucome;  Tournay,  1706. 
CELSUS,  A.  CORNELIUS:    Of   Medicine,  trans,  by  James  Grieve;  printed  by 

D.  Wilson  and  T.  Durham,  Strand,  London,  1756. 
COLLINS,  E.  TREACHER:  R.L.O.H.  Rep.,  1893,  vo1-  xiii--  P-  3°8- 
CUSSON,  M.  P.:   Remarques  sur  la  Cataracte,  a  1' Academic  des  Sciences  de 

Montpellier,  1779. 

DRAKE-BROCKMAN,  Surg.-Capt.  H.  E.:  The  Indian  Oculist  and  his  Equip- 
ment, Trans,  of  the  O.S.  of  the  U.K.,  vol.  xv.,  1895. 
DRAKE-BROCKMAN,  Lieut.-Col.  E.  F. :  The  Indian  Oculist  and  his  Equipment, 

Trans,  of  the  O.S.  of  the  U.K.,  vol.  xv.,  1895. 

EKAMBARAM,  R. :  Couchers  and  their  Methods,  Ind.  Med.  Gaz.,  1910. 
ELLIOT,  R.  H.:  Couching  of  the  Lens,  Ind.  Med.  Gaz.,  August,  1906. 
ELLIOT,  R.  H.:  The  Operation  of  Couching  as  practised  in  Southern  India: 

a  Review  of   550  Cases,  Proc.  of   S.  Ind.  Branch  of   B.M.A.,  1912,  and 

Ophthalmic  Review,  vol.  xxxi.,  1912. 
ENCYCLOPEDIA  BRITANNICA. 
GALEN  :  De  partib.  art.  med. 

HAY- WILLIAMS :  Practical  Observations  on  Surgery;  London,  1803. 
HIRSCHBERG:  Centralblatt  fur  Praktische  Augenheilkunde,  February  i,  1894. 


THE  HISTORY  OF  COUCHING  13 

HIRSCHBERG:  Centralblatt  fiir  Praktische  Augenheilkunde,  1908,  vol.  xxxii., 

p.  2. 
HISTOIRE  DE  LA  MisDECiNE,  par  Kurt  Sprengel,  trad,  par  A.  J.  L.  Jourdan; 

Paris,  1815. 
HISTOIRE   DE   L'OPHTHALMOLOGIE  a   1'ficole  de  Montpellier,  par  H.  True  et 

P.  Pansier;  Paris,  A.  Moloine,  1907. 
HUDSON,  H.  C.:  R.L.O.H.  Rep.,  vol.  xviii.,  part  ii. 
MACKENZIE,  \V.:  On  the  Diseases  of  the  Eye,  4th  edit.,  London,  1854. 
MAYNARD,  F.  P.:  Ophthalmic  Review,  April,  1903 
MAYNARD,  F.  P.:  Ind.  Med.  Gaz.,  May,  1905. 
PAULUS  jEciNETA,  vol.  ii.,  Sydenham  Society,  1845-46. 
POTT,  PERCIVAL:  Remarks  on  Cataract. 

POWER,  H.:  Depression  in  Cases  of  Cataract,  Brit.  Med.  Journ.,  October,  1901. 
QUARTILLERA,   CASTiLLEY :    Arch,    de    Oftal.   Hispano-Americanos,   October, 

1904. 
SMITH,  H.:  Cataract  Couching,   Ind.  Med.  Gaz.,  May,   1905;  and  Trans,  of 

the  O.S.  of  the  U.K.,  1904,  p.  264. 

WARE,  JAMES:  The  Cataract  and  Gutta  Serena,  3rd  edit.,  London,  1812. 
WILKINSON,  Miss  K.  E. :  The  Manuscripts  of  Naples  and  the  Vatican,  etc., 

trans,  from  Albertotti,  Ind.  Med.  Gaz.,  October,  1904. 


CHAPTER  II 

THE  TECHNIQUE  OF  THE  OPERATION 

THE  writer  has  never  seen  a  native  coucher  at  work,  and 
consequently  all  his  information  on  the  subject  has  had  to  be 
gathered  from  those  who  have  been  more  fortunate  than  him- 
self in  this  respect.  There  would  appear  to  be  two  distinct 
modes  of  operating,  which  for  convenience'  sake  may  be 
spoken  of  as  the  anterior  and  the  posterior,  using  the  terms 
relatively  to  the  plane  of  the  ciliary  body  and  iris  (Figs.  6  and 
7).  We  shall  take  them  in  turn. 


FIG.  6. — ANTERIOR  OPERATION. 


FIG.  7.  — POSTERIOR  OPERATION. 


The  Anterior  Operation.— The  patient  and  operator  sit 
facing  each  other  in  a  good  light ;  both  squat  on  their  hams 
in  accordance  with  the  immemorial  custom  of  the  East  (Fig.  8). 
The  patient  is  frequently,  if  not  usually,  told  that  no  operation 
is  to  be  performed,  and  that  it  is  merely  a  question  of  putting 
medicine  into  the  eye.  He  is  directed  to  look  downward, 
and  the  coucher  raises  the  upper  lid  with  one  hand  whilst  in 
the  other  he  conceals  either  a  needle  or  a  sharp  thorn.  It 
is  said  that  the  long  needle-like  thorn  of  the  babul-tree  is 
usually  selected  for  the  purpose.  Many  of  the  patients  have 


THE  TECHNIQUE  OF  THE  OPERATION        15 

mentioned  that  their  heads  were  steadied  by  a  friend  from 
behind.  In  the  majority  of  cases,  at  least,  it  would  appear 
that  no  form  of  local  anaesthesia  is  attempted.  The  operators 
appear  to  rely  largely  on  manual  dexterity,  and  to  aim  at  com- 
pleting the  procedure  in  a  minimum  of  time.  The  needle 
or  thorn  is  thrust  suddenly  through  the  cornea,  and  on  through 
the  pupil  or  iris,  into  or  on  to  the  periphery  of  the  lens.  The 
next  movement,  which  appears  to  follow  the  first  so  rapidly 
as  practically  to  melt  into  it.  is  that  of  depression  or  re- 


FIG.  8. — THE  OPERATION  OF  COUCHING. 

clination.  In  this,  the  spot  where  the  cornea  grasps  the  shaft 
of  the  needle  serves  as  a  fulcrum.  The  operator  raises  his  end 
of  the  instrument,  and  the  opposite  one,  which  lies  either  on 
the  surface  of  the  lens  or  imbedded  in  it,  is  consequently 
depressed,  thus  carrying  the  cataract  with  it  downwards,  or 
downwards  and  backwards,  and  so  clearing  the  pupil.  In 
the  course  of  speaking  to  a  very  large  number  of  patients  thus 
operated  on,  it  has  struck  the  writer  as  most  remarkable  that 
they  made  as  little  complaint  as  they  usually  did  of  the  pain 
inflicted  on  them  during  the  operation.  They  described  the 
sensation  of  a  sudden  prick,  but  it  was  obvious  that  they 


16         COUCHING  FOR  CATARACT 

had  no  acute  recollection  of  agonising  suffering.  This  point 
is  emphasised  by  the  fact  that  in  nearly  every  case  the  operator 
tested  his  patient's  vision  immediately  after  the  operation 
by  holding  up  fingers,  coloured  cloths,  necklaces,  or  other 
common  objects,  for  triumphant  identification.  Very  great 
stress  is  laid  on  this  part  of  the  ritual,  and  the  onlookers  are 
not  allowed  to  lose  sight  of  the  wonderful  results  achieved 
by  the  operation.  There  seems  reason  to  believe  that  an 
effort  is  made  to  enter  the  point  of  the  instrument  through  the 
pupil,  and  to  pass  it  between  the  iris  and  the  lens.  This  cannot 
fail  to  be  a  difficult  thing  to  do,  as  is  evidenced  by  the  fre- 
quency with  which  we  were  able  to  discover  scars  in  the  iris, 
which  had  obviously  resulted  from  tears  at  the  time  of  the 
operation.  The  point  of  perforation  of  the  cornea  could  fre- 
quently be  discovered,  especially  if  a  loupe  were  used  for  the 
purpose.  The  relative  positions  of  the  scars  in  the  cornea 
and  iris  were  frequently  of  great  value  to  us  from  the  diagnostic 
point  of  view.  The  eye  is  bandaged  for  at  least  twenty- 
four  hours.  By  the  end  of  that  time  the  operator  has  frequently 
placed  a  safe  distance  between  himself  and  his  patients  of  the 
day  before,  and  is  seeking  fresh  dupes  in  another  village. 

The  Posterior  Operation. — Much  that  has  been  written  on 
the  preceding  method  applies  with  equal  force  to  this.  It 
is,  however,  possible  to  describe  the  technique  much  more 
accurately,  as  it  has  been  carefully  studied  at  first-hand 
by  Dr.  Ekambaram,  who  for  many  years  worked  under  the 
writer  in  the  Government  Ophthalmic  Hospital,  Madras. 
His  original  description  of  the  method  will  well  repay  a  careful 
perusal.  He  speaks  of  the  operators  as  being  ambidextrous 
and  very  skilful.  Their  surgical  equipment  (Fig.  9)  for  the 
operation  consists  of  a  small  lancet-shaped  knife,  guarded  to 
within  a  few  millimetres  of  its  tip  by  a  roll  of  cotton-wool, 
wrapped  round  it  for  the  purpose,  and  of  a  copper  probe 
4  inches  long  and  about  i£  mm.  in  diameter.  A  cotton 
thread  twisted  round  this  probe'  at  a  spot  12  mm.  from  its 
point  serves  the  same  purpose  as  the  stop  in  the  Bowman's 
needle.  From  the  point  to  this  stop  the  instrument  is  tri- 
angular in  section.  The  patient  is  directed  to  look  well  to- 
wards the  nose,  and  the  surgeon  then  gently  marks  out  the 
selected  spot  by  pressing  with  his  thumbnail  on  the  conjunctiva 


THE  TECHNIQUE  OF  THE  OPERATION        17 

covering  the  sclera,  about  8  mm.  out  from  the  cornea,  and 
about  2  mm.  below  the  horizontal  meridian.  In  some  cases 
the  operator  steadies  the  eye  by  firm  digital  pressure  exerted 
through  the  partly  everted  lower  lid.  He  next  takes  his 
lancet  in  his  hand,  and  it  will  be  observed  from  the  illustration 
(Fig.  9)  that  it  might  easily  pass  for  a  roll  of  cotton-wool; 
this,  indeed,  is  what  the  patient  is  led  to  believe  it  really  is. 
To  heighten  such  an  impression,  the  point  is  covered  with  a 
sandalwood  paste,  prepared  beforehand  coram  publico,  with 
a  good  deal  of  ostentation.  The  patient  is  informed  that  this 
"  cataract-cleansing  drug  is  about  to  be  applied  to  the  eye," 
and  under  cover  of  the  suggestion  the  operator  plunges  the 
lancet  through  the  tunic  of  the  globe  at  the  spot  already 


COTPE.R     T  ft  QBE. 


FIG.  9. — INSTRUMENTS  USED  IN  COUCHING. 

selected.  The  alarm  thus  occasioned  is  allayed  by  the  assur- 
ance that  the  "  medicinal  application  "  is  over.  The  copper 
probe  is  next  produced,  and  is  inserted  through  the  wound  up 
to  its  stop,  being  held  between  the  thumb  and  two  fingers; 
a  circular  movement  is  given  to  its  point,  the  stop  resting 
against  the  puncture,  and  serving  as  a  pivot  for  the  movement. 
According  to  Ekambaram,  the  object  is  to  tear  through  the 
suspensory  ligament  from  behind.  Immediately  following 
this  step,  a  downward  stroke  of  the  point  is  made  in  order  to 
depress  the  now  loosened  lens.  Ekambaram  graphically 
describes  the  care  taken  by  these  operators  to  impress,  alike 
on  the  patient  and  on  the  friends,  the  magical  effects  of  the 
procedure.  The  former  is  shown  a  number  of  objects,  and  is 
bidden  to  name  them  in  turn,  and  to  state  their  colour.  The 
crowning  point  is  reached  when  the  surgeon  removes  a  thread 


i8  COUCHING  FOR  CATARACT 

from  his  garment,  and  the  patient  not  merely  recognizes  it 
as  such,  but  triumphantly  tells  its  hue.  The  Western  oph- 
thalmic surgeon,  with  his  wide  incision  and  his  anxiety  for 
the  safety  of  the  vitreous,  can  never  savour  such  dramatic 
moments  as  these.  They  carry  us  back  to  the  descriptions 
of  the  early  Christian  miracles,  with  all  the  mental  and  spiritual 
associations,  which  enwrap  such  stories  as  those  of  Bartimaeus, 
and  of  the  pools  of  Siloam  and  Bethesda.  Alas  that  life's 
"  hereafters  "  should  so  often  be  fraught  with  disillusionment, 
disappointment,  and  suffering  !  Palestine  and  its  storied 
past  rise  before  us  as  we  read  how  the  vaidyan  called  for  a 
white  cloth  and  for  water,  how  he  dipped  the  cloth  in  the  fluid 
and  washed  out  the  sufferer's  eye  therewith,  how  he  made  a 
paste  and  smeared  it  over  the  skin  around  the  brow,  how  he 
closed  the  eye  with  "  clean  white  linen,"  and  then  sent  the 
erstwhile  blind  man  rejoicing  away.  Over  the  abyss  of  nearly 
twenty  centuries,  the  East  stretches  out  her  unfaltering  hand 
to  the  past  of  the  nearer  East,  whilst  the  West  looks  on  in 
wonder,  not  unmixed  with  admiration,  for  a  spirit  which  the 
corroding  passage  of  time  seems  unable  either  to  fret  or  to 
change. 

There  is  a  step  of  the  procedure  which  has  been  purposely 
left  to  the  last,  as  its  interest  is  psychologic,  and  not  surgical. 
It  is  common  to  both  methods  of  operation.  I  refer  to  the 
anointing  of  the  eye  with  the  blood  of  a  freshly  killed  fowl. 
It  is  a  measure  in  which  superstition,  cunning,  self-preservation, 
and  greed,  overwhelm  and  mask  a  faint  and  feeble  therapeutic 
design.  The  sacrificial  element  is  present,  and  a  hazy  idea  that 
the  death  of  the  votive  bird  may  turn  evil  from  the  patient 
looms  in  the  background.  Next  comes  the  need  to  mask  the 
shedding  of  the  patient's  blood,  since  he  is  often  told  that  no 
operation  is  to  be  performed,  but  that  a  mere  "  medicinal 
application  "  is  to  be  made;  the  blood  of  the  outraged  bird 
covers  the  guilt  of  the  vaidyan 's  falsehood.  Largest  of  all 
towers  the  fact  that  the  curry-pot  even  of  a  worker  of  surgical 
marvels  needs  constant  replenishing,  and  that  fowl  is  an 
excellent  substitute  for  mutton  on  such  occasions.  Lastly, 
these  men  seem  to  believe  that  the  coagulation  of  the  fowl's 
blood  helps  to  close  the  puncture.  In  view  of  the  dirty  con- 
dition of  the  instruments  which  they  introduce  into  the  interior 
of  the  eye,  this  last  factor  may  practically  be  neglected. 


CHAPTER  III 
THE  INDIAN  COUCHER  AND  HIS  HABITS 

THE  coucher  goes  by  different  names  in  different  parts  of  India. 
In  Bengal  and  in  the  United  and  Central  Provinces  he  is  known 
as  the  "  suttya  "  or  "  mal,"  and  in  the  Punjab  as  the  "  rawal." 
Ekambaram,  who  came  into  intimate  contact  with  these 
men  in  the  Madras  Presidency,  always  describes  them  as 
"  vaidyans,"  the  term  signifying  surgeons.  In  the  north  they 
are  Hindus,  of  the  Kayasth  caste,  a  class  well  known  for  its 
astuteness  and  educational  qualifications.  Drake-Brockman 
states  that  in  the  north  Mahomedan  couchers  are  rare,  whilst 
in  the  Southern  Presidency  it  appears  to  be  the  exception  to 
find  a  Hindu  doing  such  work.  Like  every  other  occupation, 
couching  in  India  is  hereditary,  the  principles  of  the  craft 
being  handed  down  from  father  to  son  by  word  of  mouth  and 
by  practical  instruction.  It  has  been  stated  that  there  is  no 
literature  on  the  subject.  This,  however,  would  appear  to  be  a 
mistake,  for  Ekambaram  learnt  that  there  are  "  some  old 
texts  written  on  palmyra  leaves  laying  down  the  method." 
A  literal  translation  of  one  of  these  runs :  "  Removing  the  lancet 
after  making  a  puncture,  insert  the  copper  probe ;  and  holding 
it  with  three  fingers,  depress  the  lens  with  the  three-sided 
edge." 

By  tradition  and  ancestral  habit,  the  coucher  is  a  wanderer 
on  the  face  of  the  earth,  and  like  a  gipsy  he  carries  his  wares, 
such  as  they  are,  to  the  very  doors  of  the  people's  homes; 
but  it  is  probable  that  in  each  of  the  large  provinces  of  India 
these  men  have  a  headquarters  of  their  own.  This  in  the 
Madras  Presidency  is  known  as  "  Kannadiputhur,"  which 
signifies  the  "  village  of  eye  operations."  During  part  of  the 
year  these  men  are  agriculturists  and  fishermen;  but  when 
the  dry  season  robs  them  of  their  occupations,  they  wander 
forth  to  practise  the  art,  with  which  their  ancestors  have  been 

19 


20 

identified  from  time  immemorial.  They  do  not,  however, 
confine  themselves  to  eye  operations,  but  practise  as  well  a 
crude  form  of  general  surgery.  Like  many  other  disciples 
of  ^Esculapius,  their  fee  is  a  very  elastic  one,  and,  in  common 
with  other  artists,  they  learn  to  know  both  the  smiles  and  the 
frowns  of  fortune.  Luxury  rarely  comes  their  way,  whilst 
hardship  and  toil  are  their  constant  lot.  Their  spare  evening 
hours  are  filled  in  with  such  arduous  and  monotonous  occupa- 
tions as  net-weaving ;  and  full  many  a  night  they  go  hungry  to 
sleep,  with  the  sun-baked  earth  for  their  only  bed. 

All,  who  have  seen  them  at  work,  agree  that  their  methods 
are  dirty  and  septic  to  a  degree,  and  the  oft-expressed  wonder 
has  ever  been,  not  that  their  results  are  so  bad,  but  that  they 
are  ever  good.  Their  surgical  equipment  is  carried  in  a 
bag  or  in  a  box,  which  would  be  considered  dirty  alongside 
of  the  tool-chest  or  work-basket  of  any  English  artisan.  The 
filth  alike  of  their  clothes,  their  hands,  and  their  person,  stagger 
description  from  a  surgical  point  of  view.  The  exact  patterns 
of  the  instruments  used  vary  in  different  parts  of  India, 
and  so  also  do  some  of  the  couchers'  customs.  Allusion  has 
already  been  made  to  the  slaughter  of  a  fowl  and  the  use  of 
its  blood  in  Southern  India.  This  is  readily  understood,  as 
the  Mahomedan  couchers  are  flesh-eaters.  In  the  north, 
where  these  experts  are  Hindus,  the  fowl  plays  no  part,  but  a 
very  subtle  form  of  deception  is  described  by  Drake-Brockman. 
Each  suttiah  carries  in  a  little  bag  a  store  of  pieces  of  dried 
membrane.  One  of  these  is  dropped  into  water  before  the 
operation  commences,  and  is  produced  at  the  psychologic 
moment  as  evidence  that  the  Indian  surgeon  can,  and  does, 
remove  the  cataract  from  the  eye,  just  as  much  as  his  Western 
brother.  This  tribute  to  our  science  is  as  subtle  as  it  is  nefarious. 
The  pieces  carried  are  of  various  tints,  in  order  that  the  colour 
of  the  cataract,  as  seen  before  operation,  may  be  matched  as 
closely  as  possible. 

Right  through  the  ages  the  shadow  of  charlatanism  has 
lain  over  the  operation  of  couching.  We  are  told  that  it  did 
so  in  Alexandria  and  in  Rome  at  the  dawn  of  the  Christian 
era,  and  from  that  time  up  to  the  present  we  find  numerous 
traces  of  it  in  literature.  Not  the  least  interesting  of  such 
comes  from  the  Dark  Ages,  and,  despite  its  pathos,  has  a 


THE  INDIAN  COUCHER  AND  HIS  HABITS     21 

distinctly  amusing  side.  The  operator  and  his  assistant  took 
the  patient  alone  into  a  darkened  room;  a  candle  was  lighted 
and  kept  carefully  behind  the  victim's  back  by  one  of  the 
knaves,  while  the  other  in  front  asked  if  he  could  see  the  flame. 
A  sham  operation  was  then  performed,  and  the  process  was 
again  repeated,  but  this  time  with  the  light  in  front ;  naturally 
the  blind  man  could  now  see  it,  and,  on  being  assured  that 
"  the  change  "  was  due  to  what  had  been  done,  his  gratitude 
was  likely  to  rise  to  the  production  of  the  necessary  fee.  If 
it  did  so,  the  impostors  speedily  made  off.  It  seems  hard 
to  believe  that  even  the  Dark  Ages  were  dark  enough  for  so 
transparent  a  trick  to  be  tried  often  in  one  town. 

In  a  recent  personal  communication,  Dr.  Ekambaram  has 
very  kindly  furnished  the  writer  with  some  additional  in- 
formation, as  new  as  it  is  interesting.  He  divides  the  Indian 
couchers,  with  whom  he  has  come  into  contact,  into  two  classes, 
the  Mahomedan  couchers  of  the  south,  whose  work  we 
mainly  meet  with  in  Madras,  and  the  Punjabis  (people  of  the 
Punjab)  from  the  north.  The  same  method  of  operation  is 
adopted  by  both,  but  there  would  appear  to  be  a  great  differ- 
ence between  the  status  and  the  attainments  of  the  two  classes. 
The  Mahomedans  are  much  the  lower  type;  their  practice 
is  confined  to  the  villages  through  which  they  roam,  and  they 
I  very  rarely  visit  big  towns.  Their  length  of  stay  is  limited 
to  one  or  two  days,  and  they  make  haste  to  escape  soon  after 
having  performed  an  operation,  "  for  fear  of  being  clubbed  for 
their  stupid  action. "  They  do  not  use  any  form  of  anaesthetic. 
On  the  other  hand,  the  Punjabi  couchers  are  described  as  in- 
telligent, respectable,  decently  clad  men,  who  confine  their 
work  to  the  towns,  and  stay  in  each  place  four  or  five  months, 
amassing  considerable  wealth  thereby.  Before  couching, 
they  drop  into  the  eye  a  fine  yellow  powder,  which  Ekambaram 
believes  to  be  stained  cocaine.  They  were,  however,  extremely 
secretive  on  this  subject,  and  refused  to  part  with  even  a  grain 
of  the  drug  at  any  price  he  could  offer.  Its  efficiency  is 
testified  to  by  the  fact  that  the  patients  remained  absolutely 
quiet  and  collected  during  the  whole  of  the  operation.  The 
cases  are  kept  under  observation  for  from  a  week  to  a  month 
after  operation,  putting  in  a  daily  attendance.  Their  results 
are  much  better  than  those  obtained  by  the  Mahomedans. 


22  COUCHING  FOR  CATARACT 

Some  of  the  fees  they  obtain  are  relatively  very  large.  An 
idea  of  their  social  status  may  be  gathered  from  the  fact  that 
carriages  are  sent  for  them  by  their  better-class  patients;  but, 
in  Ekambaram's  opinion,  the  aristocracy  of  Indian  intelli- 
gence is  learning  to  keep  aloof  from  these  men,  owing  to  the 
influence  of  the  Western  surgeons,  whose  method  of  extrac- 
tion is  steadily  establishing  itself  in  the  esteem  of  the  people 
at  large.  He  gives  credit  to  the  Punjabis  for  a  more  efficient 
technique  of  operation  than  that  practised  by  the  Maho- 
medans. 

In  this  connection  it  is  interesting  to  record  some  of  the 
opinions  of  Western  surgeons,  who  have  come  in  contact 
with  the  work  of  these  northern  men.  Captain  H.  E.  Drake- 
Brockman  had  nothing  too  bad  to  say  of  them,  and  his  uncle 
Lieut.-Colonel  E.  F.  Drake-Brockman  (formerly  of  the  Madras 
Eye  Hospital),  in  presenting  his  nephew's  paper  before  the 
Ophthalmological  Society  of  the  United  Kingdom,  estimated 
the  coucher's  successes  at  not  more  than  10  per  cent.  Lieut.- 
Colonel  Henry  Smith  went  so  far  as  to  declare  that  even  the 
best  cases,  if  followed  long  enough,  ended  in  absolute  blind- 
ness. Lieut.-Colonel  F.  P.  Maynard  formed  a  much  less  un- 
favourable estimate  of  the  coucher's  results  (46  per  cent,  of 
successes).  The  writer's  own  statistics  will  be  given  later. 
Not  the  least  interesting  of  Drake-Brockman 's  contributions 
to  the  subject  is  his  statement  that  vaccinators  and  com- 
pounders  in  the  pay  of  the  Indian  Government  are  not  infre- 
quently couchers  in  disguise.  The  full  significance  of  this 
observation  can  only  be  appreciated  by  one  who  knows  the 
East  intimately.  Scientifically,  Western  medicine  is  educating 
the  Indian  medical  man  out  into  the  light  from  pagan  depths 
of  darkness.  Even  to-day  there  are  those  of  them  who  prac- 
tise Eastern  and  Western  medicine  side  by  side.  It  would 
seem  strange  to  a  British  surgeon  to  learn  that  it  is  possible 
for  a  medical  man  (whose  qualifications,  from  an  educational 
point  of  view,  compare  favourably  with  those  of  our  home 
Universities)  to  lay  stress  before  his  patients  on  the  right 
quarter  of  the  moon,  and  on  the  correct  aspect  of  the  ground, 
for  the  gathering  of  a  particular  drug;  yet  the  writer  has 
known  this  happen,  and  that,  too,  in  the  case  of  a  medical  man 
who  held  an  important  scientific  appointment  under  Govern- 


THE  INDIAN  COUCHER  AND  HIS  HABITS     23 

ment.     The  very  fact  of  a  man  holding  a  post  under  the  British 
Raj  would  add  to  his  prestige  and  increase  the  confidence  of  the 
people  in  him.    That  such  an  one  should  advocate  and  practise 
couching  would  cause  no  surprise  to  his  own  people,  whose 
faith  in  methods  based  on  tradition  is  firmly  founded.     Some 
idea  of  the  complexity  and  confusion  of  the  Indian  mind  to- 
day may  be  gathered  from  a  knowledge  of  the  strange  blend 
of  dissimilar  lines  of  thought  in  those  who  have  adopted 
Christianity.     There  are  many  such  who  keep  a  foot  in  both 
camps,  in  a  way  that  would  have  been  thought  impossible 
by  anyone  who  had  not  been  brought  into  intimate  contact 
with  such  people.     Under  these  circumstances,  it  is  hardly 
strange  that  the  same  kind  of  thing  should  be  found  in  evidence 
in  other  lines  of  life;    and  yet  it  is  no  time  to  blame  these 
men.     Their  need — I  speak  now  from  the  scientific  stand- 
point— is  for  "  more  light."     We  ourselves  retain  to-day  the 
taint  of  superstitions  that  come  down  from  our  witch-burning 
ancestors.     Shall  we  not,  then,  be  lenient  to  those  who  have 
never  had  our  advantages  ?     As  we   flood  India  with  the 
daylight  of  true  scientific  knowledge,  the  vermin  of  ignorance 
and  superstition  will  scurry  away  to  hide.     That  the  coucher 
believes  in  himself  is  indisputable ;  that  he  resents  the  invasion 
of  our  Western  operation  is  easily  understood ;  and  that  he  must 
disappear,  washed  out  by  the  advancing  flood  of  better  methods, 
is  as  certain  as  the  fate  of  the  furrows  left  on  the  sand  by 
last  night's  tide.     Meanwhile  he  has  stopped  a  gap  and  filled 
a  place  in  the  life  of  a  nation,  and  it  behoves  us,  in  our  esti- 
mate of  him,  to  remember  that  the  highest  earthly  honour  ever 
awarded  was  given  to  a  woman  whom  the  world  despised  and 
blamed,  in  the  immortal  words:  "She  hath  done  what  she 
could." 

It  has  been  said  of  these  men  that  they  have  no  diagnostic 
powers,  and  it  is  quite  certain  that  they  sometimes  couch  the 
lens  in  cases  of  optic  atrophy,  of  glaucoma,  and  of  certain 
other  diseases,  in  which  such  a  step  is  useless  and  worse. 
It  is  fair  to  add  that  the  number  of  cases  of  this  kind  which 
the  writer  saw  was  not  large.  This  observation  is  the  more 
significant,  since  he  was  keenly  on  the  lookout  for  any  instances 
of  the  kind,  and  that,  too,  during  many  years  of  Indian 
experience  in  an  exceptionally  large  cataract  practice.  Ekam- 


24  COUCHING  FOR  CATARACT 

baram  speaks  of  a  case  of  operable  cataract  in  which  he  had 
dilated  the  pupil,  and  on  which  he  (purely  experimentally, 
and  with  no  intention  of  allowing  it  to  be  done)  asked  couchers 
if  they  would  operate.  As  soon  as  they  found  the  pupil  was 
motionless  and  dilated,  they  declined  to  undertake  any  opera- 
tion. He  comments  favourably  on  the  acumen  they  thus 
displayed. 

A  word  may  not  be  out  of  place  on  the  subject  of  the 
covering  of  the  head  of  the  patient  and  surgeon  with  a  cloth, 
as  adopted  by  some  few  couchers  during  the  operation.  Such 
a  procedure  is,  from  the  point  of  view  of  lost  light,  a  handicap 
to  the  operator,  but  it  has,  from  his  way  of  looking  at  it,  cer- 
tain advantages.  It  shuts  the  patient  off  from  the  distrac- 
tions of  his  surroundings,  which  are  otherwise  very  public; 
it  hides  the  actual  operative  procedure  from  prying  eyes; 
and  it  conceals  the  facial  and  other  evidence  of  pain.  The 
greatest  factor  of  all,  in  an  Eastern  land,  is  the  air  of  mystery 
with  which  it  shrouds  the  proceeding.  The  element  of  "  jadu  " 
(magic)  so  introduced  is  paramount  in  its  psychologic  interest. 


CHAPTER  IV 
STATISTICAL 

IN  the  Indian  Medical  Gazette  of  August,  1906,  the  writer  pub- 
lished a  review  of  125  cases  of  couching  of  the  lens  by  Indian 
vaidyans.  On  March  13,  1912,  the  total  had  swollen  to  550, 
and  an  analysis  of  all  the  cases  was  conducted  on  the  same 
lines  as  those  followed  in  the  earlier  communication.  Subse- 
quent to  this,  Major  H.  Kirkpatrick,  the  succeeding  Superin- 
tendent of  the  Madras  Eye  Hospital,  analysed  350  cases  of 
the  Mahomedan  operation  (the  first  120  of  which  overlapped 
the  series  already  dealt  with  by  the  writer) ,  and  in  forwarding 
them  made  the  comment  that  "  these  statistics  are  remark- 
ably similar  to  those  of  your  series."  In  view  of  the  consist- 
ency of  the  results  obtained  and  of  the  large  figures  dealt  with 
it  seems  safe  to  assume  that  reliable  deductions  can  now  be 
drawn. 

The  main  headings  of  these  statistics  will  next  be  taken  up. 
Before  commencing  to  do  so,  it  is  of  special  interest  to  note 
that  the  methods  observed  by  Colonel  Drake- Brockman  in 
other  parts  of  India  tally  closely  with  those  described  by 
Ekambaram  in  Southern  India.  This  is  the  more  readily 
understood  when  we  remember  that  many  of  the  operators  in  the 
South  of  India  come  from  the  north.  This  observation  puts 
our  cases  on  all  fours  with  those  published  from  other  parts  of 
India. 

It  is  perhaps  difficult  to  form  an  accurate  opinion  as  to 
how  far  the  figures  before  us  represent  the  best  results  attained 
by  the  coucher.  His  apologists  might  urge  that  only  his  failures 
would  come  to  English  hospitals.  On  the  other  hand,  there 
can  be  little  doubt  that  quite  a  considerable  number  of  eyes 
are  lost,  after  couching,  from  panophthalmitis  and  from 
shrinkage  of  the  eye  following  iridocyclitis.  Patients  in  such 
conditions  will  often  stay  away  from  hospital  owing  to  their 

25 


26        COUCHING  FOR  CATARACT 

very  hopelessness ;  and  even  if  they  do  resort  to  English  treat- 
ment, they  will  stoutly  deny  that  their  eyes  have  been  inter- 
fered with.  Thus  in  both  ways  the  records  of  such  failures 
are  lost,  making  the  net  result  appear  better  than  it  really 
is.  In  collecting  our  statistics,  we  were  constantly  on  the 
lookout  for  all  cases  of  couched  lens,  and  have  notes  of  a  large 
number  of  patients  who  did  not  come  to  hospital  for  the  eye 
in  which  reclination  had  been  performed. 

Considerable  interest  attaches  to  the  study  of  the  column 
showing  the  periods  that  elapsed  between  the  Mahomedan 
operation  and  the  date  at  which  the  patient  came  under  ob- 
servation. Only  6 '82  per  cent,  were  seen  within  the  first 
month,  and  but  17-88  per  cent,  within  the  first  six  months. 
The  following  six  months  added  only  5-65  per  cent.  The  great 
mass  of  the  eyes  had  been  operated  on  from  one  to  ten  years 
previous  to  being  seen.  This  in  itself  would  indicate  that  the 
cases,  from  which  our  observations  were  made,  were  drawn 
from  the  mass  of  the  people  rather  than  from  the  coucher's 
failures  alone. 

An  argument  in  support  of  the  reliability  of  our  figures 
may  be  drawn  from  the  extraordinarily  widespread  opinion, 
amongst  both  European  and  Indian  practitioners,  that  the 
vaidyans'  results  are  appalling.  The  writer  had  the  opportunity 
of  talking  on  the  subject  with  a  large  number  of  men  who 
practised  in  the  parts  where  couching  was  rifest,  and  their 
testimony  was  unanimous.  Ekambaram,  who  has  already 
been  freely  quoted,  has  made  these  men's  methods  a  special 
study,  and,  impressed  by  the  wholesale  destruction  of  eyes 
he  had  witnessed,  made  the  request  that  the  matter  should 
be  brought  to  the  notice  of  Government  through  the  Surgeon- 
General,  which  was  accordingly  done.  Apropos  of  the  figures 
now  under  discussion,  Colonel  Drake-Brockman  wrote:  "I 
have  seen  quite  enough  to  convince  me  of  the  truth  of  Major 
Elliot's  statement,  and  that  his  percentage  of  actual  loss  of 
eyes  from  this  cause  alone  is  by  no  means  exaggerated." 
Major  Smith  has  given  his  experience  of  the  disastrous  results 
of  couching,  and  has  gone  so  far  as  to  say  that  even  the  best 
cases,  if  followed  long  enough,  end  in  absolute  blindness. 
With  this  last  observation  we  cannot  wholly  agree,  nor  do  our 
statistics  in  the  south  bear  out  his  opinion  that  "  partial 


STATISTICAL  27 

dislocation  is  more  frequent  than  the  complete  dislocation 
in  the  hands  of  adepts  in  the  art."  He  is  satisfied  that  a  great 
majority  of  cases  go  bad  immediately,  either  from  suppuration 
or  from  iridocyclitis,  and  that  a  large  proportion  of  the  re- 
mainder are  but  imperfectly  couched.  Other  surgeons,  too, 
have  testified  to  the  disastrous  nature  of  the  vaidyans'  results. 

Only  4*94  per  cent,  of  the  total  number  of  cases  lie  below 
the  age  of  36,  and  nearly  69  per  cent,  lie  between  the  ages  of 
40  and  60.  This  is  in  accordance  with  what  we  know  of  senile 
cataract  in  India.  Of  the  fourteen  cases  which  show  an  age 
of  30  or  below,  eight  may  be  excluded  as  having  probably 
given  their  ages  too  low;  one  was  lost  by  suppuration  after 
couching,  and  no  deduction  can  be  made  as  to  the  condition 
before  operation;  in  two  it  seems  probable  that  the  cataract 
was  secondary  to  syphilitic  iritis :  they  were  two  eyes  of  different 
persons;  in  one  patient  the  operation  failed  on  both  sides: 
the  eyes  were  congenitally  imperfect,  and  in  addition  iritis 
was  present  as  a  complication  in  one  of  them.  In  the  sixth 
the  operator  evidently  burst  the  capsule  and  let  out  its  semi- 
fluid contents;  but  the  nucleus  remained  in  situ  and  blocked 
the  pupil.  It  is  obvious  that  couching  is  an  extremely  un- 
suitable operation  for  this  class  of  case;  it  requires  for  its 
easy  performance  a  firm  lenticular  mass,  but  as  will  be  seen 
when  we  come  to  discuss  the  morbid  anatomy  of  the  subject, 
it  is  quite  possible  to  dislocate  one  of  these  fluid  lenses  intact. 
There  is  at  least  a  presumption  that  in  such  cases  the  posterior 
operation  has  been  performed,  though,  in  view  of  the  tough- 
ness of  the  capsules  of  not  a  few  Morgagnian  cataracts,  one  can- 
not say  with  certainty  in  all  such  cases  that  the  anterior 
operation  has  not  been  done. 

No  table  is  more  interesting  than  that  which  gives  the  state 
of  vision  when  the  patients  came  under  observation.  In 
only  10-59  Per  cent,  was  the  vision  £  and  upward.  In  another 
11-05  per  cent,  the  vision  was  £  to  TV,  in  9-64  per  cent,  it  was 
T(J  to  -s\,  and  in  7-05  per  cent,  it  was  a  finger-count  at  2  feet 
or  less.  The  figures  given  refer  in  each  case  to  the  vision 
corrected  with  lenses.  If  every  case  that  got  a  vision  of  iV 
and  upward  be  considered  a  success,  the  coucher  can  claim 
21-64  per  cent.  Again,  if  anything  from  rV  vision  to  the 
ability  to  count  fingers  close  to  the  face  be  counted  as  partial 


28  COUCHING  FOR  CATARACT 

success,  the  figure  for  this  class  is  16-69  Per  cent.  This  is  very 
much  more  liberal  treatment  than  would  be  accorded  to  the 
cataract  statistics  of  any  modern  surgeon. 

A  further  light  is  thrown  on  the  above  figures  by  a  study  of 
the  table  showing  the  duration  of  vision  after  couching.  Of 
the  45  successful  cases,  23  of  them,  or  more  than  50  per  cent., 
had  been  couched  less  than  two  years  before ;  9  more  had  been 
couched  between  two  and  three  years,  and  n  from  three  to 
ten  years.  In  two  this  detail  was  unmarked.  The  great  pre- 
ponderance of  short  histories  in  the  cases  of  successful  opera- 
tion is  significant. 

Against  the  vaidyans'  figures  we  may  place  the  statistics  of 
the  Madras  Hospital,  even  so  long  ago  as  1903,  and  before 
a  rigid  system  of  antisepsis  had  been  introduced.  Recoveries 
numbered  96  per  cent.,  poor  results  2  per  cent.,  and  failures 
2  per  cent.  These  figures  would  indicate  that  the  coucher 
was  losing  60  per  cent,  more  eyes  than  the  hospital  did  even 
then.  If  the  vast  number  of  eyes  submitted  to  couching  be 
taken  into  account,  this  60  per  cent,  of  avoidable  loss  totals 
up  to  a  staggering  figure.  Nor  must  we  disregard  the  fact 
that,  even  amongst  the  successes,  the  average  vision  obtained 
is  greatly  in  favour  of  the  Western  surgeon. 

The  table  showing  the  causes  of  failure  will  repay  a  careful 
study.  The  figure  for  iritis  and  iridocyclitis  comes  to  35*76 
per  cent,  of  the  total  number  of  cases ;  glaucoma  accounts  for 
11-05  per  cent.,  imperfect  dislocation  of  the  lens  for  8-94  per 
cent.,  retinal  detachment  for  3-53  per  cent.,  optic  atrophy 
(including  one  case  of  optic  neuritis  supervening  as  a  septic 
complication  of  the  operation)  for  2-59  per  cent.,  retinitis 
pigmentosa  and  retinitis  punctata  albescens  for  0*49  per  cent., 
retinochoroiditis  for  1-41  per  cent.,  vitreous  opacities  (ad- 
mittedly a  very  vague  term)  for  1-18  per  cent.,  and  failure 
due  to  operation  on  a  congenitally  imperfect  eye  for  0-23  per 
cent. ;  3*53  per  cent,  are,  unfortunately,  unaccounted  for  owing 
to  deficiencies  in  the  notes. 

In  the  great  majority  of  cases  ruined  by  iridocyclitis  the 
inflammation  made  its  appearance  within  a  .few  days  after 
operation;  but  there  were  instances  in  which  this  complica- 
tion was  delayed  for  a  long  period.  Our  notes  show  three  cases 
in  which  it  came  on  from  one  and  a  half  to  three  years  after 


STATISTICAL  29 

operation,  one  case  after  seven  years,  and  one  after  ten  years. 
There  are  also  a  few  doubtful  cases  in  which  a  history  of  three 
or  four  months  of  useful  vision  preceded  the  inflammatory 
attack.  In  one  case  at  least,  sympathetic  ophthalmia  would  ap- 
pear to  have  destroyed  the  other  eye  two  years  after  operation. 

Similarly,  it  was  found  in  most  cases  of  glaucoma  that  the 
access  of  high  tension  came  on  within  a  few  days  of  operation. 
There  were  six  exceptions  to  this  rule,  three  commencing  from 
two  to  ten  months  after  the  couching,  one  five  years,  one  six 
years,  and  one  fourteen  years  after.  From  a  clinical  point  of 
view,  the  cause  of  the  onset  of  glaucoma  in  these  cases  is  ob- 
scure. Many  of  them  appear  to  be  associated  with  irido- 
cyclitis,  but  we  must  leave  this  matter  for  the  present.  We 
shall  have  occasion  to  deal  with  it  much  more  fully  under  the 
heading  of  pathology. 

Imperfect  dislocation  of  the  lens  accounted  for  failure  in 
8 '94  per  cent,  of  all  cases  operated  on.  In  such  cases  the 
suspensory  ligament  appeared  to  have  been  incompletely  torn, 
with  the  result  that  the  lens  swung,  as  it  were,  on  a  hinge. 
Sometimes  this  hinge  lies  above,  and  the  cataract  falls  quite 
out  of  the  line  of  sight  when  the  patient  is  recumbent,  but 
flaps  back  to  block  the  pupil  when  the  erect  attitude  is  assumed. 
In  other  cases,  even  when  the  hinge  is  laterally  placed,  the 
same  thing  may  happen,  but  much  more  rarely. 

From  a  clinical  point  of  view,  detachment  of  the  retina 
figures  in  only  3-53  per  cent,  of  the  total  cases ;  but  it  is  unlikely 
that  this  represents  the  true  figure.  In  a  number  of  instances 
an  ophthalmoscopic  examination  was  quite  impossible,  either 
because  the  pupil  was  blocked,  or  because  no  fundus  reflex 
could  be  obtained.  Our  pathological  material  has  shown 
that  in  many  such  cases  the  retina  was  totally  detached, 
whereas,  in  arriving  at  the  figure  above  given,  we  were  deal- 
ing only  with  those  instances  in  which  the  diagnosis  was 
established  by  the  aid  of  the  ophthalmoscope. 

Ten  of  the  cases  in  which  failure  was  ascribed  to  optic 
atrophy  showed  no  improvement  in  vision  after  operation. 
Their  histories  indicate  that  the  atrophic  condition  was  present 
before  operation,  and  there  seems  to  be  a  fair  presumption 
that  the  coucher  mistook  the  condition  for  cataract,  or  at 
least  failed  to  recognise  its  true  nature.  In  one  case  acute 


30  COUCHING  FOR  CATARACT 

optic  neuritis  appears  to  have  supervened  as  a  septic  com- 
plication of  the  operation.  This  throws  an  interesting  light 
on  those  pathological  specimens  in  which  a  cone  of  exudate 
is  to  be  seen  passing  from  an  inflamed  optic  nerve  to  the 
ciliary  body. 

In  six  cases  there  was  evidence  of  choroido-retinitis  with 
secondary  optic  atrophy.  Four  of  them  showed  no  improve- 
ment after  operation,  whilst  two  were  improved  thereby; 
subsequently  even  these  two  lost  their  vision  by  the  progress 
of  the  retinitis.  In  the  four  cases  the  retinitic  condition  was 
evidently  antecedent  to  the  operation,  and  was  either  mistaken 
for  cataract  or  at  least  was  not  recognised.  It  is  impossible 
to  say  positively,  from  the  history  of  the  other  two,  whether 
it  existed  prior  to  operation,  but  it  possibly  did. 

In  one  case  of  retinitis  pigmentosa,  in  one  of  retinitis 
punctata  albescens,  and  in  eleven  of  glaucoma,  the  vaidyan 
appears  to  have  mistaken  the  condition  present  for  cataract. 
At  least,  the  vision  was  not  bettered  even  temporarily  by  the 
operation  in  any  of  these  patients. 

Of  the  five  cases  shown  under  vitreous  opacities,  three 
were  obviously  due  to  the  inflammation  of  the  uveal  tract 
posterior  to  the  iris ;  two  others  were  due  to  haemorrhage  into 
the  vitreous.  Many  more  cases  would  undoubtedly  have 
shown  vitreous  opacities  had  the  pupils  been  patent.  More- 
over, our  pathological  data  show  that  not  a  few  of  the  cases 
in  which  the  fundus  reflex  was  absent  presented  dense  exudates 
into  the  vitreous  cavity.  This  subject  will  be  dealt  with  at 
length  under  pathology.  The  genesis  of  haemorrhage  into  the 
vitreous  is  obvious,  and  it  is  more  than  probable  that  if  all 
the  cases  were  seen  at  an  early  stage  the  figure  for  this  com- 
plication would  be  much  higher. 

From  the  foregoing  notes,  it  is  clear  that  the  native  coucher 
undertakes  a  certain  number  of  what  we  should  recognise  as 
inoperable  cases.  It  is  possible  that  in  many  of  them  a 
secondary  cataract  is  present ;  but  it  is  clear  that  his  diagnostic 
powers  are  low.  He  is  a  standing  menace  to  the  safety  of  the 
public. 

It  has  from  time  to  time  been  suggested  that  the  presence  of 
the  lens  in  the  vitreous  chamber  brings  about  retinal  changes. 
The  author  is  not,  however,  aware  of  any  reliable  evidence 


STATISTICAL  31 

either  ophthalmoscopic  or  pathological  to  support  this  view 
As  far  as  possible,  all  cases  seen  in  Madras  were  submitted 
to  ophthalmoscopic  examination,  whether  the  couching  had 
resulted  in  success  or  failure.  We  were  unable  to  discover 
any  characteristic  change  which  could  be  attributed  to  the 
couching.  A  large  percentage  of  the  fundi  examined  appeared 
to  be  absolutely  normal.  The  most  frequent  departure 
from  normal  was  an  undue  distinctness  of  the  choroidal  vessels, 
which  was  evidently  due  to  the  absorption  of  the  pigment 
of  the  pigmentary  layer  of  the  retina.  It  is  probably  this 
phenomenon  which  has  misled  some  into  the  belief  that  couch- 
ing is  followed  by  changes  in  the  retina  allied  to  those  in  re- 
tinitis  pigmentosa  sine  pigmento.  This  absorption  of  retinal 
pigment  is,  however,  well  known  to  occur  in  other  conditions, 
as,  for  instance,  in  high  myopia;  moreover,  in  the  case  of 
couched  eyes,  it  is  not  accompanied  by  the  changes  in  the 
disc  and  vessels  characteristic  of  retinitis  pigmentosa,  or  by 
the  equally  characteristic  night  blindness.  In  searching  for 
the  explanation  of  this  phenomenon,  four  solutions  at  once 
present  themselves  for  consideration:  (i)  It  might  be,  as  has 
been  suggested,  a  result  of  couching;  (2)  it  might  be  due  to 
the  alterations  in  the  refractive  conditions  under  which  the 
fundus  is  seen;  (3)  it  might  be  a  physiological  abnormality; 
and  (4)  it  might  be  an  accompaniment  of,  and  a  direct  result 
of  pathological  changes  in  the  eye  accompanying  the  develop- 
ment of  cataract.  The  third  suggestion  is  thrown  out  by  our 
experience  of  normal  native  eyes.  An  important  light  has 
been  thrown  on  the  whole  question  by  the  observation  that  a 
similar  change  is  found  in  quite  a  number  of  eyes  which  have 
been  submitted  to  cataract  extraction.  This  disposes  of  the 
first  idea,  that  the  presence  of  the  lens  in  the  vitreous  would 
account  for  the  phenomenon.  Neither  experience  nor  theory 
support  the  view  that  an  alteration  in  refraction  is  responsible 
for  the  appearance.  We  are  thus  narrowed  down  to  the  con- 
clusion that  the  pigmentary  change  is  an  accompaniment  of 
the  development  of  cataract  in  a  certain  percentage  of  eyes, 
and  is  independent  of  the  method  of  operation  resorted  to  for 
the  relief  of  that  condition. 

In  this  connection,  two  interesting  observations  deserve 
record,  as  they  possibly  throw  an  important  sidelight  on  the 


32  COUCHING  FOR  CATARACT 

question  at  issue:  (i)  Lenses  extracted  in  India  differ  from 
those  met  with  in  European  practice,  in  the  amount  of  colour- 
ing matter  they  contain.  A  very  large  percentage  of  them 
are  stained  with  pigment,  which  is  frequently  of  a  deep  tint. 
Many  of  them  are  dark  brown,  and  a  few  are  almost  black. 
(2)  Cyanopsia  is  of  extraordinarily  frequent  occurrence  as 
a  sequela  during  convalescence  after  cataract  extraction  in 
Madras.  Over  50  per  cent,  of  the  patients  complain  of  it, 
whilst  only  2-8  per  cent,  suffer  from  erythropsia,  and  1-2  per 
cent,  from  yellow  or  green  vision. 

We  thus  find  two  very  striking  differences  between  Western 
and  Eastern  cataract  experience,  and  there  is,  to  say  the  least 
of  it,  a  strong  suggestion  that  the  phenomena  are  closely  con- 
nected with  each  other — in  other  words,  that  the  cyanopsia 
is  a  result  of  the  retina  becoming  tired  out  for  the  perception 
of  yellow  by  long  exposure  to  a  tropical  light  filtering  through 
a  brown  or  yellow  lens.  There  is  also  a  strong  presumption 
that  the  coloration  of  the  lenses  is  due  to  a  migration  of  pig- 
ment, which  takes  place  during  the  development  of  cataract 
in  the  East,  a  migration  which  is  directed  from  the  pigmentary 
layer  of  the  retina,  and  probably  from  other  parts  as  well, 
towards  and  into  the  developing  cataracts.  If  the  above 
hypothesis  is  correct,  we  might  assume  that  the  retina  is  more 
likely  to  be  functionally  affected  in  an  adverse  sense  when 
deprived  of  the  protection  ordinarily  afforded  by  its  pig- 
mentary layer.  In  order  to  test  this,  the  author  some  years 
ago  made  a  systematic  examination  of  a  large  number  of  eyes 
from  which  cataracts  had  recently  been  removed,  with  the 
object  of  ascertaining  whether  cyanopsia  was  complained  of, 
principally  or  only,  in  those  cases  in  which  the  choroidal 
vessels  were  seen  to  stand  out  with  unusual  distinctness  under 
ophthalmoscopic  examination.  The  depth  of  discoloration 
of  the  lenses  was  at  the  same  time  noted  in  each  case.  The 
results  obtained  appear  to  favour  the  views  we  have  above 
enunciated,  but  they  were  not  sufficiently  conclusive  to 
justify  the  formation  of  a  decisive  opinion.  It  must  be  re- 
membered that,  whilst  a  tinge  of  colour  runs  through  most 
of  the  cataractous  lenses  removed  in  the  East,  there  are  very 
wide  variations,  not  only  in  the  depth  of  the  pigmentation, 
but  also  in  the  actual  coloration  present.  Some  of  them  are 


STATISTICAL  33 

yellow,  some  reddish-brown,  some  almost  coal  black,  with  every 
intermediate  shade  between.  It  is  possible  that  our  investi- 
gations failed  for  want  of  competent  assistance  with  the 
spectroscopic  analysis  of  the  lenses.  An  interesting  field  for 
research  is  here  presented.  That  deep-seated  metabolic 
changes  accompany  the  development  of  a  cataract  has  been 
shown  by  J.  Burdon  Cooper,  and  it  seems  not  unlikely  that  the 
apparent  prevalence  of  lenticular  opacities  in  tropical  coun- 
tries may  be  closely  bound  up  with  the  metabolic  changes 
we  have  described.  It  is  probable  that  the  retinal  pigment 
layer  is  not  the  only  source  of  the  deep  discoloration  of  the 
lenses  met  with  by  surgeons  in  India.  A  point  in  favour  of 
the  argument  we  have  been  elaborating  is  that  some  years 
ago  McHardy  published  the  analysis  by  MacMunn  of  the 
spectrum  of  the  pigment  obtained  from  a  black  cataract. 
This  was  found  to  be  quite  distinct  from  blood-pigment,  and 
to  be  allied  to  the  cell- pigment,  which  gives  coloration  to 
ectodermal  structures  in  animals  (Trans,  of  the  O.S.  of  the 
U.K.,  1882). 

To  collect  the  780  cases  now  under  review  has  taken  over 
twelve  years,  and  the  writer  is  deeply  indebted  to  Major 
Kirkpatrick  for  his  great  generosity  in  allowing  his  230  cases, 
the  later  ones  of  the  series,  to  be  made  use  of  in  this  paper. 
Throughout  all  these  years  one  definite  purpose  has  been  kept 
in  the  forefront — viz.,  to  ascertain  the  real  value  of  lens 
couching.  After  making  every  possible  allowance  for  the 
vaidyan,  the  fact  remains  that  he  is  a  standing  menace  to 
society,  and  that  he  should  be  suppressed.  His  methods 
are  crude,  filthy,  and  dangerous;  his  results  are  so  appalling 
that  anyone  unacquainted  with  the  ignorance  and  credulity 
of  the  Indian  ryot  would  think  it  impossible  for  him  to  continue 
to  exist.  His  impudent  lying  includes  not  merely  a  grossly 
exaggerated  statement  of  his  own  successes,  but  extends 
to  the  most  barefaced  falsehoods  as  to  the  nature  of  the  results 
obtained  in  European  hospitals.  It  may  be  permissible  to 
quote  one  instance — unfortunately,  far  from  a  solitary  one  in 
Madras  experience.  Some  years  ago  a  peasant,  who  had  had 
a  cataract  removed  in  the  Government  Ophthalmic  Hospital, 
and  whose  recollections  of  his  treatment  there  were  most 
kindly,  returned  for  operation  on  the  second  eye.  On  the 

3 


34        COUCHING  FOR  CATARACT 

steps  of  a  temple,  within  a  hundred  yards  from  our  operating 
theatre,  this  man,  who  had  travelled  several  hundred  miles 
for  aid,  was  induced,  by  a  tissue  of  impudent  lies,  to  sit  down 
and  submit  to  couching.  A  few  days  later  he  presented  him- 
self at  the  out-patient  room  with  panophthalmitis.  There  is 
no  branch  of  ophthalmic  disease  and  treatment  in  India 
which  so  profoundly  impresses  the  Western  surgeon's  imagina- 
tion as  this  one.  Remember  that  cataract  strikes  a  man  down 
in  his  maturity,  at  a  period  of  his  life  when  he  has  begun  to 
reap  the  benefits  of  his  earlier  years  of  toilsome  industry. 
His  pay  and  his  home  expenses  are  both  alike  at  their  maxi- 
mum. He  is  treading  the  higher  rungs  of  the  official  or  business 
ladder,  and  is  endeavouring  to  afford  his  children  the  best 
education  in  his  power.  Few  pictures  are  more  pitiful  than 
that  of  such  a  man  passing  hopefully  down  an  avenue  of  credu- 
lity and  ignorance  to  a  fate  to  which  death  itself  is  often  pre- 
ferred, the  horror  of  a  great  and  lifelong  darkness.  On  the 
other  hand,  Government,  the  protector  of  the  poor,  stands 
by  powerless  to  interfere,  and  supinely  watches  this  catastro- 
phic waste  of  human  energy.  The  cords  that  bind  the  in- 
dividuals are  woven  a  million-fold  together  to  tie  the  hands  of 
the  rulers  more  securely  still.  Every -civilized  nation  of  to- 
day recognises  it  as  a  first  principle,  that  it  is  its  duty  to 
protect  its  people  from  avoidable  harm,  and  that  to  deal  with 
preventable  blindness  is  one  of  its  primary  duties.  That  men 
and  women,  who  ought  to  be  burden-bearers,  should  be  thrown 
instead  as  a  burden  on  their  relatives  or  on  the  State,  is  a 
social  evil  of  no  small  magnitude.  One  does  not  presume  to 
blame  either  the  State  or  the  people.  It  would  obviously  be 
idle  and  wrong  to  do  so.  The  plain  indication  is  to  arouse  the 
medical  conscience  of  the  country,  to  start  men  thinking  of 
the  evils  which  are  so  rife  in  the  land ;  and  so  to  introduce  a 
ferment,  as  it  were,  into  the  medical  mind  of  India,  and  then 
to  leave  it  to  do  its  work.  It  is  not  suggested  that  the  country 
is  ripe  for  legislation  on  the  subject.  The  people  are  not 
ready  for  it.  There  aie,  however,  two  distinct  avenues  along 
which  an  advance  may  safely  be  made — viz.,  (i)  the  syste- 
matic dissemination  of  knowledge  through  Government 
agencies  amongst  the  people ;  (2)  the  improvement  of  ophthal- 
mic medical  education.  A  movement  in  these  two  directions 
is  already  on  foot,  and  in  time  it  will  bear  much  fruit. 


BEING  THE  HUNTERIAN  LECTURES  DELIVERED  BEFORE  THE 
ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND  ON 
FEBRUARY  ig  AND  21,  1917 

THE  material  at  our  disposal  consists  of  54  globes,  the  great 
majority  of  which  were  removed  in  the  Madras  Ophthalmic 
Hospital  in  the  period  from  1911  to  1915,  though  some  are  of 
much  older  date.  They  were  placed  in  5  per  cent,  formalin 
immediately  on  removal,  and  were  subsequently  frozen  and 
bisected.  In  a  number  of  instances  one  half  of  the  eye  was 
submitted  to  microscopic  examination  after  suitable  sectioning. 
Each  of  the  half-globes  and  a  number  of  microscopic  specimens 
have  been  photographed  for  purposes  of  illustration.  It  will 
be  convenient  to  classify  our  observations  under  a  number  of 
separate  headings. 

The  Various  Directions  in  which  Dislocation  of  the  Lens  is 
found  to  have  taken  place. 

Before  considering  this  subject  in  the  light  of  the  patho- 
logical specimens  before  us,  it  is  necessary  to  make  certain 
preliminary  statements : 

1.  Inasmuch  as  all  our  material  is  derived  from  blinded 
eyes,  it  is  obvious  that  we  are  dealing  with  the  coucher's 
failures  alone,  and  are  excluding  his  successes.      In  a  very 
large  percentage  of  the  latter  the  lens  is  seen,  during  life,  to 
be  floating  freely  in  the  vitreous,  apparently  untrammelled 
by  adhesions. 

2.  The  position  in  which  we  find  the  lens  on  bisection  of 
the  eyeball  is  not  necessarily  that  into  which  it  was  thrust  at 
the  time  of  operation,  for  the  changes  which  occur  in  the  eye 

35 


36  COUCHING  FOR  CATARACT 

as  a  result  of  inflammatory  action  may  profoundly  alter  the 
position  into  which  the  lens  was  originally  forced  by  the 
coucher.  Nor  must  we  forget  that  in  those  globes,  in  which 
the  cataract  is  not  tightly  tethered  by  adhesions,  gravity 
plays  a  part. 

Having  thus  cleared  the  ground,  we  may  start  with  the 
statement  that,  though  the  lens  may  be  displaced  in  any  direc- 
tion within  the  sclero-corneal  coat,  backward  dislocations 
are  by  far  the  most  common,  whilst  forward  ones  were  only 
found  4  times  in  the  whole  series  of  54  globes.  None  the  less, 
each  of  these  latter  cases  possesses  considerable  interest. 

Forward  Dislocations. — (i)  In  No.  8  *  the  couching  in- 
strument passed  through  the  limbus,  and  the  track  of  the 
wound  can  be  plainly  followed  in  microscopic  sections.  The 
ciliary  body  was  pushed  bodily  away  from  the  sclera,  and  the 
lens  nucleus  was  forcibly  thrust  into  the  space  formed  by  this 
cyclodialysis  (PI.  II.,  Fig.  10) ;  it  is  to  be  seen  imbedded  in  a 
mass  of  inflammatory  exudate,  whilst  its  capsule,  with  some 
of  the  cortex,  lies  in  the  normal  situation. 

(2)  In  No.  44  the  capsule  and  the  nucleus  of  a  Morgagnian 
cataract  are   seen   floating  in  the  vitreous  chamber  (PL  II., 
Fig.  n).     During  life  the  nucleus  frequently  passed  backwards 
and  forwards  between  the  aqueous  and  vitreous  cavities.    The 
same  phenomenon,  though  rare,  has  been  observed  in  other 
couched  eyes. 

(3)  No.  6 1  is  probably  an  instance  of  the  same  kind  of  thing 
having  happened  at  an  earlier  period  (PI.  II.,  Fig.  12).     Now, 
however,  the  small  dark  Morgagnian  nucleus  is  seen  fixed  in 
the  lower  part  of  the  anterior  chamber,  into  which  it  doubtless 
gravitated  by  its  own  weight,  and  there  set  up  inflammatory 
mischief,  which  led  to  its  adhesion  to  the  surrounding  parts, 
and  to  its  becoming  fixed  in  situ  by  the  formation  of  organising 
exudate. 

(4)  In  No.  108  the  only  evidence  of  lens  material  present 
was  the  capsule  of  a  Morgagnian  cataract,  which  lay  impacted 
in  the  lower  part  of  the  anterior  chamber  (PI.  II.,  Fig.  13).     On 

*  The  whole  series  of  specimens  has  been  presented  to  the  Royal  College 
of  Surgeons  of  England.  The  present  chapter  forms  a  descriptive  catalogue 
of  the  most  instructive  of  them.  The  original  Madras  numbers  within  the 
bottles  have  been  retained,  and  are  here  quoted  for  ready  reference. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  39 

section,  Morgagnian  fluid  escaped,  and  no  trace  of  a  nucleus 
could  be  detected.  It  is  of  interest  to  record  that  the  writer 
has,  on  a  number  of  occasions,  operated  on  Morgagnian  catar- 
acts in  which  the  lens  nucleus  had  been  reduced  to  the  thickness 
of  a  lamellar  disc,  or  in  which  no  trace  of  a  nucleus  could  be 
detected.  In  this  case  no  adhesions  had  formed,  and  during 
the  transit  of  the  specimen  to  England  the  capsule  fell  from  its 
position  to  the  bottom  of  the  bottle. 

Backward  Dislocations. — Dislocations  backward  are  the 
rule,  and  very  wide  variations  are  found  both  in  the  complete- 
ness and  in  the  direction  of  the  displacement. 

Those  in  which  the  lenses,  or  their  nuclei,  have  been  com- 
pletely dislocated  into  the  vitreous,  and  there  lie  floating  more  or 
less  freely  (PI.  II.,  Fig.  14),  are  9  in  number.  In  7  of  them 
the  cataracts  were  Morgagnian,  and  in  the  2  others  there 
was  a  bulky  nucleus  with  a  thin  covering  of  stiff  cortex.  In 
7  the  tension  of  the  globe  was  high ;  in  6  the  retina  was  com- 
pletely or  nearly  completely  detached,  and  in  2  of  them  it  was 
so  much  folded  as  to  limit  the  movements  of  the  lens. 

From  a  consideration  of  the  lenses  found  floating  in  the 
vitreous,  we  turn  to  that  of  those  which  were  entangled  in  a 
more  or  less  consistent  inflammatory  exudate  occupying  the 
vitreous  chamber  (PL  II. ,  Fig.  15).  During  life  such  lenses  were 
reported  to  be  fixed,  or  nearly  so.  In  the  specimens  they 
are  seen  to  be  nested  in  a  mass  of  exudate,  which  holds  them 
imprisoned  against  the  ciliary  body  and  the  back  of  the  iris. 
Usually  this  exudate  is  limited  in  quantity  and  is  confined  to 
the  anterior  portion  of  the  eye,  and  principally  to  the  neigh- 
bourhood of  the  dislocated  lens.  More  rarely  it  is  very  abun- 
dant, and  occupies  a  large  part  or  even  the  whole  of  the  vitreous 
chamber  (PI.  III.,  Fig.  16).  We  shall  deal  with  this  exudate 
more  fully  at  a  later  stage ;  for  the  present  it  suffices  to  state 
that  it  is  inflammatory  in  origin,  and  that  it  contains  a  large 
number  of  cells.  Of  the  6  cases  which  form  this  group,  3  were 
Morgagnian  cataracts;  5  were  certainly  dislocated  in  their 
capsule,  the  sixth  is  hidden  in  such  dense  exudate  that  it 
cannot  be  clearly  seen.  It  is  desirable  to  make  it  clear  that 
intermediate  forms  are  found  between  this  group  and  the 
previous  one.  In  other  words,  there  is  no  hard-and-fast 
line  between  the  cases  in  which  the  lenses  float  freely  in  the 


40  COUCHING  FOR  CATARACT 

vitreous  and  those  in  which  they  are,  to  a  greater  or  less  degree, 
tethered  by  the  pathological  thickening  of  the  hyaloid  body. 

We  have  next  to  consider  a  group  of  10  eyeballs,  in  each  of 
which  the  dislocated  cataract  was  firmly  fixed  to  the  ciliary  body 
and  to  the  back  of  the  iris  by  definitely  organised  fibrous  tissue 
(PI.  III.,  Fig.  17).  These  globes  present  certain  well-marked 
features  of  some  interest :  (i)  The  percentage  of  Morgagnian 
cataract  is  much  lower  than  that  in  the  preceding  groups,  and 
corresponds  closely  with  the  normal  frequency  of  this  form 
of  cataract  in  Indian  practice.  (2)  The  cataract  was  dislo- 
cated in  its  capsule  in  no  less  than  8  of  the  10  cases. 

(3)  The  retina  was  totally  detached  in  2  and  very  extensively 
so  in  one;   in  every  one  of  the  remaining  7  this  membrane 
showed  the  presence  of  white  dots,  apparently  on  its  surface. 

(4)  The  time  which  had  elapsed  since  operation  in  the  cases 
falling  under  this  group  is  remarkable.     In  one  it  is  given  as 
seven    months;    in    2    others   there    is    no    history  ;    in   the 
remaining  7  the  duration  was  from  two  to  twenty  years,  with 
an  average  of  well  over  seven  years.     The  association  of  the 
presence  of  white  dots  with  these  long  histories  is  remarkable, 
and  will  be  taken  up  in  a  later  section. 

No.  99  (PL  III.,  Fig.  18)  is  a  specimen  of  special  interest  for 
two  reasons — viz.,  (i)  the  cataract  is  fixed  to  the  globe  un- 
usually far  back,  being  attached  to  the  retina  a  little  behind 
the  equator  of  the  eye ;  (2)  the  dislocation  has  taken  place  in  an 
upward  direction,  and  therefore  against  the  action  of  gravity. 
From  time  to  time  we  meet  clinically  with  a  couched  lens 
whose  suspensory  ligament,  though  torn  through  over  a  wide 
circumference,  has  been  spared  at  one  part,  which  acts  as  a 
hinge.  The  loosened  lens  flaps  backwards  and  forwards 
with  the  movements  of  the  eye,  at  times  obstructing  the 
pupil,  and  at  others  being  lost  to  sight.  If  the  hinge  is  above, 
the  cataract  usually  blocks  the  pupil  when  the  head  is  erect; 
but  one  meets  with  cases  in  which  the  lens  floats  up  out  of  the 
way  unless  the  face  is  thrown  forward  into  the  horizontal 
plane;  this  is  apparently  due  to  a  check-ligament  action  of 
the  remaining  suspensory  fibres  of  the  lens,  acting  on  a  lens 
which  is  very  nearly  of  the  same  specific  gravity  as  the 
vitreous  in  which  it  lies.  Should  inflammation  be  set  up  in 
such  an  eye  and  the  lens  become  involved  in  the  exudate,  it 


PLATE  III 

FIG.  16:  SPECIMEN  No.  197.  —The  exudate  into  the  vitreous  cavity  is  abun- 
dant and  opaque,  concealing  the  dislocated  cataract.  (Time  since 
operation,  one  month.) 

FIG.  17:  SPECIMEN  No.  37. — The  lens  is  tied  to  the  back  of  the  iris  and 
ciliary  body  by  firm  organised  exudate,  which  is  continuous  with  and 
part  of  the  cone  of  inflammatory  material  representing  the  shrunken 
vitreous.  Notice  the  advanced  organisation  evident  in  the  apex  of  the 
cone  near  the  optic  nerve,  also  the  white  line  apparently  representing 
the  hyaloid  canal.  Some  large  dots  and  many  small  ones  are  to  be  seen 
on  the  retina. 

FIG.  18:  SPECIMEN  No.  99. — A  large  lens  in  its  capsule  is  dislocated  upward 
and  inward,  and  is  adherent  to  the  retina  by  inflammatory  bands.  The 
retina  shows  very  numerous  white  dots.  There  is  a  tendency  to  equa- 
torial scleral  staphyloma. 

FIG.  19:  SPECIMEN  No.  171. — The  retina  is  totally  detached  and  rolled  up 
tight;  cysts  both  false  and  true  are  to  be  seen  in  it.  The  lens  is  im- 
bedded in  a  mass  of  inflammatory  exudate,  matted  to  the  iris  and 
ciliary  body  in  front,  and  to  the  retina  behind ;  the  ciliary  body  is  detached. 
The  coagulated  subretinal  exudate  gives  the  specimen  the  appearance 
of  a  half-marble.  The  sclera  is  folded  owing  to  the  shrinking  of  the  eye- 
ball. 

FIG.  20:  SPECIMEN  No.  119. — From  before  backwards  can  be  seen  the  iris, 
the  remains  of  the  lens  capsule,  and  the  thickened  anterior  layer  of  the 
hyaloid.  The  lens  is  dislocated  backward  between  the  second  and 
third  of  these,  and  is  wedging  them  apart.  The  retina  is  detached  over 
nearly  half  the  globe;  this  is  in  large  part  determined  by  the  pull  of  the 
shrinking  thickened  anterior  hyaloid  layer. 

FIG.  21 :  SPECIMEN  No.  46. — The  hard  dark  nuclear  cataract  had  been  de- 
pressed; it  lies  in  front  of  the  unruptured  anterior  hyaloid  membrane, 
and  therefore  outside  the  vitreous  cavity. 


PLATE   III. 


FIG.  16  (No.!i97).— Left  eye,  lower  half.gjV    o  *  FIG.  17  (No.  37).— Left  eye,  lower  half. 


FIG.  18  (No.  99). — Left  eye,  upper  half.  FIG.  19  (No.  171). — Left  eye,  upper  half, 


FIG.  20  (No.  1 19). — Right  eye,  upper  half.  FIG.  21  (No.  46). — Left  eye,  lower  half. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  43 

may  become  fixed,  as  in  this  case,  in  the  upper  segment  of 
the  globe. 

When  we  come  to  speak  of  the  changes  found  in  the  vitreous, 
we  shall  have  occasion  to  refer  to  the  frequency  with  which 
the  hyaloid  body  is  represented  by  a  shrunken  cone  with  its 
apex  at  the  optic  nerve  and  its  base  in  the  neighbourhood  of 
the  ora  serrata.  This  form,  which  is  well  known  to  patho- 
logists,  is  due  to  the  anatomical  attachments  of  the  vitreous 
body,  and  to  the  fact  that  the  latter  undergoes  shrinkage 
after  being  thickened  and  opaciiied  by  the  presence  of  inflam- 
matory exudate.  In  studying  the  present  collection,  one 
cannot  fail  to  be  struck  with  the  fact  that  the  exudate,  which 
fixes,  or  helps  to  fix,  the  lens  in  its  pathologic  position,  is  one 
with,  and  part  of,  this  cone-shaped  new  formation.  Before 
leaving  the  consideration  of  this  group,  we  must  once  again 
point  out  that  no  hard-and-fast  line  separates  it  from  the  pre- 
ceding one,  and  that  intermediate  links  between  the  two  can 
easily  be  pointed  to. 

In  ii  globes,  dislocated  cataracts  were  found  matted 
between  the  iris  and  ciliary  body  in  front  and  the  completely 
detached  retina  behind.  It  is  very  difficult  to  say  what  the 
nature  of  the  original  cataracts  was,  since  all  that  one  can 
now  find  is  a  nucleus,  usually  rather  dark-coloured,  imbedded 
in  a  mass  of  inflammatory  tissue  (PL  III.,  Fig.  .19).  These 
nuclei  are  undergoing  steady  reduction  in  bulk  as  the  result  of 
phagocytic  action.  In  7  of  the  n,  the  lens  remnants  lie 
either  within  the  complete  capsule  or  in  its  near  neighbourhood. 
The  interior  of  the  capsule  is  usually  found  to  have  been 
invaded  by  the  mass  of  inflammatory  and  organising  tissue 
which  mats  together  all  the  structures  (i.e.,  the  iris,  the  ciliary 
body,  the  remains  of  the  lens,  and  the  detached  retina),  and 
which  occludes  the  angle  of  the  anterior  chamber.  The  com- 
pleteness of  the  dislocation  varies  greatly.  In  some  cases  the 
lens  is  hardly  moved  from  its  usual  position,  and  lies  in  front 
of  the  anterior  hyaloid  membrane,  whilst  in  others  it  is  displaced 
into  the  vitreous  cavity.  In  one  instance  the  detachment  of 
the  retina  and  the  inflammatory  changes  are  sharply  limited 
to  the  lateral  half  of  the  eye  towards  which  the  cataract  was 
dislocated,  but  this  case  belongs  more  to  the  next  group  than 
to  the  one  we  are  now  discussing. 


44  COUCHING  FOR  CATARACT 

There  are  three  outstanding  and  very  important  features 
common  to  these  cases:  (i)  In  the  great  majority  of  them 
there  is  evidence  that  the  operation  was  followed  by  severe 
iridocyclitis  ;  (2)  9  of  the  n  were  shrinking  eyes  with 
low  tension ;  and  (3)  the  time  which  had  intervened  between  the 
couching  and  the  enucleation  was  between  one  and  two  years 
in  every  case  save  one,  in  which  it  is  probable  that  the  furnished 
statement  of  three  months  was  inaccurate.  It  will  be  noticed 
that  the  histories  are  much  shorter  than  those  in  the  previous 
group.  This,  together  with  the  other  two  points  mentioned, 
indicates  that  we  have  to  deal  with  a  condition  widely  different 
from  that  in  any  of  the  previous  groups.  Here  the  inflamma- 
tory process  had  been  induced  by  a  septic  infection  of  the  eyes 
of  a  decidedly  more  virulent  character,  though  it  fell  short 
of  that  acme  of  infectivity,  which  leads  in  so  many  cases  of 
the  Indian  operation  to  panophthalmitis  and  destruction  of 
the  globe  within  a  few  weeks. 

We  come  next  to  a  group  of  5  cases,  which  have  one 
feature  in  common — viz.,  that  the  cataract,  though  dislocated 
backwards,  lies  distinctly  in  front  of  the  anterior  hyaloid  mem- 
brane, and  therefore  outside  the  vitreous  cavity  (PL  III.,  Figs. 
20  and  21).  In  3  of  them  the  solid  parts  of  the  lenses  have 
been  pushed  back  from  their  original  position  in  such  a  way 
that  they  act  like  wedges,  forcibly  keeping  the  anterior  hyaloid 
membrane  in  a  plane  posterior  to  that  which  it  would  normally 
occupy.  Out  of  these  5  cataracts  4  were  cortico-nuclear ; 
the  fifth  was  too  much  altered  for  it  to  be  possible  to  state  what 
its  nature  was.  In  certainly  4  out  of  the  5  moderately 
severe  iridocyclitis  had  followed  the  couching,  but  the  exuda- 
tive process  was  a  much  less  severe  one  than  that  which 
characterised  the  specimens  of  the  previous  group.  The  con- 
sequence was  that  there  was  no  such  matting  of  all  the  parts 
concerned  as  is  there  seen.  In  every  case  the  detachment 
of  the  retina  was  complete  or  nearly  so,  but  in  not  one  was 
the  lens  enwrapped  in  its  folds.  This  we  may  attribute  to 
two  causes:  (i)  a  merely  contributory  one,  that  the  vitreous 
cavity  was  not  invaded;  and  (2)  that  the  infection  was  less 
virulent,  and  the  inflammation  consequently  less  severe,  than 
in  the  members  of  the  previous  group. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  45 

There  is  a  small  group  of  3  cases  in  which  the  remains  of 
the  lens  lie  in  situ  in  the  periphery  of  the  capsule,  whilst  the 
central  portion  has  disappeared.  These  resemble  the  peri- 
pheral after-cataracts  not  infrequently  seen  following  the 
extraction  of  a  not  fully  mature  lens. 

In  conclusion  we  have  to  mention  2  specimens  in  which 
the  condition  found  was  so  unusual  that  it  would  scarcely 
have  been  possible  to  have  anticipated  its  occurrence. 

The  first  of  these  was  one  of  the  earliest  globes  sectioned. 
A  Morgagnian  lens,  entire  in  its  capsule,  was  found  thrust 
behind  the  retina.  It  lay  against  the  scleral  coat  close  to  the 
ciliary  body;  it  had  detached  the  retina  over  a  large  area  in 
the  neighbourhood  of  the  ora  serrata,  and  had  led  to  a  com- 
plete separation  of  it  on  that  (the  nasal)  half  of  the  eye.  The 
edge  of  the  detached  retina  had  contracted  adhesions  to  the 
front  of  the  lens  capsule,  and  was  much  puckered  in  that 
neighbourhood,  doubtless  as  the  result  of  cicatrisation. 

The  second  specimen  (PI.  IV.,  Fig.  22)  shows  many  features 
in  common  with  the  last.  The  lens  is  entire  in  its  capsule,  and 
is  almost  certainly  Morgagnian ;  the  tear  in  the  retina  through 
which  it  was  thrust  has  now  cicatrised  up,  leaving  a  puckered 
scar.  The  retina  is  totally  detached,  and  on  section  the  catar- 
act lay  as  far  forward  as  the  separation  of  that  membrane  would 
permit.  The  pupil  was  blocked  by  exudate,  and  atrophic 
scars  in  the  iris  showed  that  there  had  been  extensive  lacera- 
tion of  that  membrane.  The  globe  was  removed  a  year  after 
operation. 

The  sequence  of  events  in  these  two  cases  was  possibly 
as  follows:  The  posterior  operation  may  have  been  adopted 
and  the  incision  placed  far  back;  a  wide  tear  in  the  retina 
resulted;  the  lens,  completely  separated  from  its  attach- 
ments, was  kept  entire  by  the  toughness  of  the  Morgagnian 
capsule,  whilst  the  fluidity  of  its  contents  made  its  insinuation 
through  the  retinal  tear  an  easy  matter.  The  fact  that  a 
case  has  recently  been  recorded  in  which,  in  a  boy  of  seventeen, 
the  lens  spontaneously  escaped  through  a  2  mm.  trephine 
hole  throws  a  sidelight  on  such  cases  as  these. 


46  COUCHING  FOR  CATARACT 

Accidental  Injuries  to  Other  Structures  than  the  Lens  during 

Couching. 

Though  the  primary  object  of  the  Indian  cataract  coucher 
is  to  depress  the  lens,  he  may  accidentally  injure  any  or  all 
of  the  other  structures  of  the  eye.  Evidence  of  such  damage 
is  obtained  both  clinically  and  pathologically. 

The  Cornea. — Opaque  scars  on  the  cornea  are  quite  fre- 
quently seen  in  the  out-patient  room  in  eyes  which  have  been 
subjected  to  the  anterior  operation,  but  are  rendered  invisible 
in  formalin-mounted  specimens  owing  to  the  ©pacification  of 
the  membrane.  Other  evidence  of  corneal  injury  is,  however, 
available. 

In  No.  9  a  corneal  fistula  is  present,  lying  to  the  inner  side  of 
the  centre  of  the  eye  (PI.  IV. ,  Fig.  23) .  The  lamellae  immediately 
surrounding  it  are  largely  replaced  by  connective  tissue;  the 
whole  thickness  of  the  membrane  is  markedly  reduced,  and  the 
lining  epithelium  is  irregular  and  vacuolated.  The  iris  is  very 
closely  adherent  to  the  back  of  the  cornea  near  the  fistula,  but 
more  loosely  attached  farther  out.  There  has  evidently  been 
some  ulceration  of  the  cornea  and  the  formation  of  a  limited 
staphyloma,  which  burst  at  a  later  date,  leaving  the  fistula  now 
seen.  It  is  probable  that  the  point  of  fistulisation  was  deter- 
mined by  the  use  of  a  septic  instrument  at  the  time  of  opera- 
tion, and  that  septic  keratitis  followed,  leading  to  early  per- 
foration with  entanglement  of  the  iris.  On  the  other  hand, 
it  is  possible  that  the  enclavement  of  the  iris  occurred  as  the 
instrument  was  withdrawn.  In  either  case,  the  later  sequence 
of  events  included  a  secondary  rise  in  tension,  the  formation 
of  a  staphyloma,  and  a  fresh  perforation  at  the  weakest  point, 
resulting  in  the  production  of  a  permanent  fistula. 

In  No.  45  the  lens  capsule  is  adherent  to  the  back  of  the 
cornea,  the  iris  being  widely  torn,  and  being  probably  also 
involved  in  the  synechia  (PI.  IV.,  Fig.  24).  All  that  remains 
of  the  lens  is  a  brown  nucleus;  the  cataract  was  evidently 
Morgagnian.  It  is  probable  that,  after  the  escape  of  the  fluid 
it  contained,  the  lax  capsule  prolapsed  into  the  wound,  either 
with  the  gush  of  fluid  which  accompanied  the  withdrawal  of 
the  instrument  or  at  a  later  date. 

In  No.  116  it  is  the  retina  which  is  impacted  in  the  cornea] 


PLATE  IV 

FIG.  22:  SPECIMEN  No.  138. — A  large  Morgagnian  cataract  in  its  capsule  lies 
dislocated  behind  the  totally  detached  retina;  the  tear  in  the  front  part 
of  the  lower  half  of  the  retina,  through  which  the  lens  was  thrust,  is  now 
represented  by  a  wide  puckered  scar. 

FIG.  23:  SPECIMEN  No.  9. — A  whole-section  showing  a  persistent  fistula  of 
the  cornea. 

FIG.  24:  SPECIMEN  No.  45. — A  brown  nucleus  dislocated  downward  in  its 
capsule  lies  tightly  adherent  to  the  back  of  the  iris  and  ciliary  body; 
it  is  fixed  there  by  organised  exudate,  the  bands  from  which  radiate  out 
into  the  retina  and  are  determining  the  detachment  of  that  membrane. 
The  iris  is  torn  on  the  nasal  side,  and  through  the  tear  there  passes  a 
capsulo-corneal  synechia. 

FIG.  25:  SPECIMEN  No.  116. — The  retina  is  totally  detached,  and  rolled  up 
like  a  closed  umbrella.  There  is  a  retino-corneal  synechia.  The  lens 
has  been  reclined;  it  probably  lay  outside  the  vitreous  cavity.  The 
subretinal  exudate,  coagulated  by  preparation,  gives  the  eyeball  the 
appearance  of  a  cut  marble.  During  life  the  pressure  of  the  lens,  which 
had  been  wedged  backward,  thrust  the  retina  and  the  parts  adherent 
to  it  backward  below,  thus  displacing  the  subretinal  exudate  there,  and 
causing  it  to  bulge  in  the  upper  half  of  the  eyeball;  this  bulge  effectually 
obliterated  the  upper  part  of  the  anterior  chamber,  whilst  the  direct 
pressure  of  the  lens  obliterated  the  chamber  below. 

FIG.  26:  SPECIMEN  No.  306. — There  is  a  pigmented  scar  running  through 
the  thickness  of  the  sclera,  just  behind  the  level  of  the  ciliary  processes. 
The  optic  disc  is  deeply  cupped,  and  the  anterior  chamber  is  very  shallow. 

FIG.  27:  SPECIMEN  No.  306. — Low-power  magnification  of  the  previous 
specimen  shows  a  persistent  fistula  running  through  the  substance  of 
the  sclera ;  the  ciliary  body  is  impacted  in  its  deeper  part,  and  there  is  a 
filtering  scar  on  its  surface. 


PLATE    IV. 


FISTUt-A 


FIG.  22  (No.  138). — Right  eye,  lower  "half. 


FIG.  23  (No.  9). — Left  eye,  whole  section. 


FIG.  24  (No.  45).— Right  eye,  lower  half. 


FIG.  25  (No.  116). — Right  eye,  nasal  half. 


FIG.  26  (Xo~3oG). — Left  eye,  upper  half. 


FIG.  27  (No.  306). — Microscopic  section, 
low  power. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  49 

wound  (PI.  IV.,  Fig.  25).  It  seems  likely  that  in  this  instance 
the  sequence  of  events  was  as  follows :  A  severe  plastic  inflam- 
mation resulted  from  the  couching,  and  involved  among  other 
structures  a  capsular  synechia,  which  had  formed  at  the  time 
of  operation  or  soon  after.  The  vitreous  became  heavily  in- 
fected, and  the  consequent  exudate  became  adherent  on  the 
one  hand  to  the  retina,  which  thereby  underwent  total  detach- 
ment, and  on  the  other  to  the  capsule  and  its  synechia.  The 
progressive  contraction  of  the  scar-tissue  then  drew  the 
retina  into  the  wound.  This  would  appear  to  be  the  most 
likely  explanation,  but  it  is  not  impossible,  in  dealing  with 
such  an  operation  as  couching,  that  the  retinal  detachment 
was  very  extensive,  and  that  the  injury  inflicted  provided  a 
path  along  which  a  direct  prolapse  of  the  retina  may  have 
occurred. 

The  Sclera.  —  A  very  large  number  of  Indian  cataract 
couchers  perform  the  posterior  operation,  and  therefore  make 
their  preliminary  incision  in  the  sclera  outside  the  limbus. 
Dr.  Ekambaram,  who  has  watched  these  men  at  work,  believes 
that  they  deliberately  endeavour  to  avoid  the  ciliary  body,  and 
it  also  looks  as  if  some  of  them  purposely  place  their  incision 
below  the  external  rectus  muscle.  Like  his  Western  confrere, 
the  Indian  surgeon  does  not  always  succeed  in  placing  his 
incision  just  where  he  wishes  to;  this  is  not  surprising,  as 
many  of  these  men  work  without  any  local  anaesthetic,  and  not 
a  few  of  their  patients  are  nervous  and  unruly  to  the  last 
degree.  Moreover,  it  is  more  than  probable  that  there  are 
different  opinions  amongst  couchers  as  to  the  best  site  for 
the  preliminary  cut.  These  considerations  will  serve  to  ex- 
plain the  variety  of  location  of  the  scars,  as  found  in  the  speci- 
mens before  us;  indeed,  some  such  explanation  is  called  for, 
since  the  cicatrices  may  be  found  as  far  forward  as  the  limbus, 
and  as  far  back  as  the  equator  of  the  globe ;  what  is  more,  they 
may  be  seen  in  the  present  collection,  not  only  in  their  common 
situation,  on  or  near  the  horizontal  meridian,  but  in  any  of  the 
quadrants  of  the  eye. 

As  a  rule,  the  evidence  of  injury  to  the  sclera  is  to  be  in- 
ferred from  the  interference  with  the  parts  beneath  that  coat, 
and  such  instances  will  be  taken  up  when  we  come  to  consider 
the  lesions  of  the  ciliary  body  and  choroid;  but  occasionally 

4 


50  COUCHING  FOR  CATARACT 

we  have  been  fortunate  enough  to  hit  off  the  scleral  scar  either 
in  the  original  division  of  the  globe  or  during  the  course  of  sec- 
tioning of  part  of  it  for  the  purpose  of  microscopic  examination. 

In  No.  306  the  track  of  the  original  wound  can  be  seen  as  a 
pigmented  scar  in  the  sclera  immediately  behind  the  line  of  the 
ciliary  processes  (PI.  IV.,  Fig.  26).  Microscopic  sections  show— 
(i)  that  the  pigmentation  of  the  deeper  part  of  the  scar  is  due 
to  the  impaction  of  uveal  tissue  in  its  depth ;  (2)  that  there  is  a 
fistulous  scar  running  right  through  the  thickness  of  the  sclera ; 
and  (3)  that  the  subconjunctival  tissue  in  the  neighbourhood 
of  the  wound  is  permeated  by  large  open  spaces  lined  with 
endothelium  (PL  IV.,  Fig.  27).  It  is  clear  that  a  limited 
measure  of  filtration  had  been  established,  but  this  apparently 
proved  insufficient  to  keep  the  tension  of  the  eye  from  rising, 
as  is  shown  by  the  deep  glaucomatous  cupping  and  by  the 
obliteration  of  the  anterior  chamber. 

No.  43  shows  a  scar  a  little  farther  back,  in  the  neighbour- 
hood of  the  ora  serrata;  but  in  this  case  the  wound  appears 
to  have  healed  solidly.  The  pigment  of  the  underlying  uveal 
tissue  shows  a  marked  disturbance,  whilst  before  the  specimen 
was  cut  it  was  observed  that  the  sclera  was  pigmented  in  the 
neighbourhood  of  the  cicatrix. 

In  No.  8  the  wound  lay  in  the  limbus,  and  the  solidifying 
scar  can  be  traced  right  through  the  thickness  of  the  ocular 
tunic  and  down  to  the  mass  of  inflammatory  exudate  which 
surrounds  the  dislocated  lens,  and  fills  the  angle  of  the  anterior 
chamber.  Here,  again,  the  pigment  can  be  traced  some 
distance  up  into  the  scar,  in  which  the  uveal  tissue  is 
distinctly  entangled. 

The  Uveal  Tract. — In  quite  a  large  number  of  couched  eyes 
one  can  see,  during  life,  evidence  of  past  injury  to  the  iris  in 
the  form  of  more  or  less  extensive  scars,  many  of  which  pro- 
bably also  involve  the  ciliary  body.  Moreover,  in  other  cases, 
one  can  infer  the  presence  of  injury  to  the  ciliary  body  and  the 
choroid  from  the  existence  of  pigmented  cicatrices  in  the 
sclera.  Anatomically,  the  present  series  of  eyeballs  affords 
additional  information  on  this  head.  Iris  scars  are  fairly 
common.  In  one  case,  already  referred  to,  the  coucher  had 
effected  a  cyclodialysis ;  in  3  more  the  wounds  lie  across 
the  front  parts  of  the  ciliary  processes  ;  in  6  they  involved 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  51 

the  region  of  the  orbiculus  ciliaris.  and  in  one  of  these  the 
scar  lies  as  much  on  the  choroid  as  it  does  on  the  ciliary  body 
(PI.  II.,  Fig.  15);  lastly,  in  4  the  wounds  lie  well  behind  the 
ciliary  body,  being  placed  in  2  of  them  just  in  front  of  the 
.equator,  and  in  2  more  well  behind  it.  Taking  them  as  a 
whole,  the  wounds  tend  to  be  grouped  in  the  outer  quadrant 
of  the  eye,  above  or  below  the  horizontal  meridian.  It  has 
already  been  pointed  out  that  this  is  in  accordance  with 
Ekambaram's  evidence  as  to  the  site  of  selection  for  the 
incision  in  the  posterior  operation.  Far  the  best  method  of 
examining  these  scars  is  by  transillumination  with  a  bright 
light  from  behind.  Some  points  of  interest  remain  for  con- 
sideration. 

In  No.  44  the  wound  lay  behind  the  ciliary  processes  (PI.  II., 
Fig.  u),  the  instrument,  most  probably  at  its  point,  tore,  off 
a  tongue-shaped  process  from  the  posterior  surface  of  the 
iris,  thus  thinning  that  membrane  over  this  area;  the  torn 
portion  contracted  an  adhesion  to  the  subjacent  hyaloid  mem- 
brane, which  was  itself  infiltrated  with  inflammatory  exudate; 
the  appearance  presented  is  curious  and  interesting. 

In  several  of  the  globes  scar-tissue  radiates  from  the 
wound  area  into  the  surrounding  tissues,  and  is  then  a  strong 
contributory  factor  in  the  production  of  retinal  detachment. 
In  one  globe  (No.  130)  two  scars  are  to  be  seen,  one  of  which 
was  evidently  placed  too  far  back  by  mistake  (PI.  V.,  Fig.  28) ; 
the  eye  also  furnishes  contributory  evidence  that  things  did  not 
go  well  during  the  operation,  for  the  iris  is  very  widely  lacerated. 
It  seems  probable  that  the  patient  was  refractory  or  the  sur- 
geon unskilful.  In  any  case,  it  is  clear  that  the  instrument 
was  introduced  a  second  time. 

In  No.  148  a  caseating  mass  in  the  eyeball  (PI.  V.,  Fig.  29), 
lying  behind  the  equator,  was  found  to  contain  a  fragment  of 
metal ;  the  latter  was  most  unfortunately  lost  at  the  time  the 
section  was  cut,  but  it  was  presumably  the  tip  of  the  couching 
instrument,  and  its  presence,  taken  with  the  facts  that  the 
wound  was  placed  very  far  back  and  that  dislocation  of  the  lens 
was  not  effected  by  the  operation,  would  seem  to  indicate  that 
the  patient  moved  violently  and  that  the  operator  failed  in  his 
purpose.  The  strong  but  strictly  localised  inflammation 
excited  suggests  that  the  metallic  fragment  was  of  copper, 


52  COUCHING  FOR  CATARACT 

and  this  is  in  accordance  with  the  known  facts  of  the  case, 
since  the  probes  used  by  these  men  to  displace  the  lens  are  made 
of  that  metal. 

No.  72  is  also  a  specimen  of  special  interest.  Here,  too, 
the  puncture  lay  behind  the  equator,  and  there  seems  to 
have  been  some  difficulty  in  penetrating  the  choroidal  and 
retinal  coats,  which  were  carried  in  front  of  the  instrument, 
the  result  being  a  wide  separation  of  these  two  tunics  from 
their  scleral  bed  (PI.  V.,  Fig.  30). 

No.  297,  removed  six  weeks  after  the  operation,  is  an  eye- 
ball which  had  undergone  panophthalmitis,  and  had  burst 
through  a  point  in  the  sclera  on  the  horizontal  meridian 
somewhere  in  front  of  the  equator.  It  is  probable  that  a 
septic  wound  of  entrance  determined  the  site  of  the  bursting. 
The  lecturer  has  seen  suppurating  globes  in  which  the  sclera 
at  one  point  had  completely  sloughed,  the  intense  inflammation 
present  bearing  witness  to  the  violence  of  the  infective  process 
excited. 

•  Uveitis. — The  type  of  inflammation  of  the  uvea  found  in 
these  specimens  was  plastic,  and  was  mostly  confined  to  the 
iris  and  ciliary  body.  The  intensity  of  the  inflammation 
varied  very  greatly.  In  a  number  of  specimens  the  evidence 
of  inflammatory  action  was  either  absent  or  only  to  be  detected 
on  very  careful  examination.  On  the  other  hand,  a  large 
number  of  cases  present  themselves  at  Indian  hospitals  in 
which  suppurative  panophthalmitis  has  followed  the  operation 
of  couching.  In  Madras  such  globes  were  eviscerated,  as  it 
was  considered  dangerous  to  enucleate  them,  and  much  in- 
teresting material  has  thus  been  lost.  All  the  intermediate 
stages  between  the  very  slight  and  the  very  severe  inflamma- 
tions can  be  traced  in  the  specimens  before  us.  This  is  in 
accordance  with  what  we  should  have  expected  in  what  was 
practically  a  series  of  inoculations  of  healthy  globes  with 
pathological  materials,  which  varied  enormously  in  their 
nature  and  in  the  quantity  introduced.  Nor  must  we  forget 
the  great  differences  in  the  ages  and  in  the  conditions  of  health 
of  the  patients.  The  plastic  mass  poured  out  from  the  ciliary 
body  and  iris  had  in  many  cases  enveloped  the  remains  of 
the  lenses  (PI.  V.,  Fig.  31;  also  PI.  III.,  Fig.  19),  which  can  be 
seen  in  process  of  disintegration  under  the  action  of  phago- 


PLATE  V 

FIG.  28:  SPECIMEN  No.  130. — The  iris  shows  a  deep  jagged  tear.  There  are 
two  scars  made  at  the  operation,  one  over  the  posterior  part  of  the 
ciliary  body,  the  other  near  the  equator  of  the  eye.  Numerous  white 
dots  are  seen  on  the  choroid  and  iris. 

FIG.  29:  SPECIMEN  No.  148. — There  is  a  localised  patch  of  inflammation 
within  the  globe  behind  the  equator;  in  this  was  found  a  foreign  body, 
probably  the  tip  of  the  copper  probe  u  ,ed  in  the  operation.  It  lay  in 
the  vitreous  cavity  within  the  retina,  which  is  totally  detached. 

FIG.  30:  SPECIMEN  No.  72. — The  operation  scar  can  be  seen  on  the  temporal 
side  of  the  sclera  behind  the  equator.  The  choroid  and  retina  are  ex- 
tensively detached  on  this  side,  having  evidently  been  pushed  before  the 
instrument  before  it  succeeded  in  penetrating  them.  To  the  nasal 
side  in  the  anterior  part  of  the  vitreous  chamber  lies  a  cone  of  exudate, 
the  apex  of  which  (posteriorly)  is  adherent  to  the  retina,  and  has  raised 
it  from  its  bed  in  the  form  of  a  shallow  bleb.  The  cornea  fell  in  during 
preparation;  it  was  ulcerated.  The  anterior  chamber  was  full  of  pus 
and  blood.  What  is  left  of  the  lens  lies  buried  at  the  base  of  the  cone 
of  exudate  already  referred  to,  being  bound  thereby  to  the  ciliary  body 
and  to  the  back  of  the  iris. 

FIG.  31:  SPECIMEN  No.  171. — A  whole-section  of  the  eye  shown  in  Fig.  19. 
For  details  of  description  refer  to  that  figure. 

FIG.  32:  SPECIMEN  No.  171. — Low-power  magnification  of  a  portion  of  the 
specimen  shown  in  the  previous  figure.  To  the  right  is  seen  the  inflamed 
and  matted  iris;  beneath  this  lies  a  mass  of  inflammatory  exudate  in 
which  the  curled  remains  of  the  lens  capsule  can  be  traced.  In  this  mass 
of  exudate  the  lens  nucleus  lies  imbedded,  its  margins  being  surrounded 
by  large  phagocytes. 

FIG.  33:  SPECIMEN  No.  171. — High-power  magnification  of  portion  of  the 
previous  specimen,  showing  some  of  the  phagocytes  much  enlarged. 
Notice  their  processes  invading  the  lens  substance. 


PLATE   V. 


FIG.  28  (No.  130).— Left  eye,  upper  half.  FIG.  2g!(No.  148).— Left  eye.  upper  half. 


FIG.  30  (No.  72).  — Right  eye,  lower  half.  FIG.  31  (No.  171).— Left  eye,  whole  section. 


FIG.  32  (No.  171). —  Microscopic  section, 
low  power. 


FiG.'33  (No.  171).— Microscopic  section, 
high  power. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  55 

cytosis  (PI.  V.,  Figs.  32  and  33)  or  of  fluid  absorption. 
Evidence  of  calcification  of  the  lens  was  obtained  in  at  least 
one  specimen  (PI.  VI.,  Fig.  35),  and  the  same  process  was  also 
found  at  work  in  the  uveal  coat  of  several  others.  The 
rupture  of  the  lens  capsule  often  provides  a  ready  path  of 
ingress  for  the  inflammatory  exudate,  which  can  then  be  seen 
filling  the  cavity  of  the  capsule  as  well  as  surrounding  it.  The 
curly  remains,  both  of  the  anterior  and  of  the  posterior 
portions  of  the  capsule,  can  be  clearly  traced  in  many 
of  the  specimens,  imbedded  in  dense  masses  of  organising 
inflammatory  exudate.  In  several  such,  the  absence  of  the 
capsule  opposite  or  to  one  side  of  the  pupillary  area,  and  the 
curled-up  ends  of  the  elastic  membrane,  mark  the  spot  where 
rupture  was  effected  at  the  time  of  operation. 

In  only  one  instance  has  any  evidence  of  proliferative 
uveitis  come  to  light,  and  in  this  one  the  nodule  in  the  iris 
consists  of  mononuclear  lymphocytes;  epithelioid  and  giant 
cells  are  conspicuous  by  their  absence.  The  interest  of  this 
observation  centres  in  the  fact  that  a  large  number  of  these 
globes  were  removed  with  the  object  of  guarding  against  the 
occurrence  of  sympathetic  ophthalmia,  or  of  making  safer  the 
performance  of  an  extraction  in  the  opposite  eye.  So  far  as  the 
first  indication  is  concerned,  it  would  appear  that  the  danger  of 
sympathetic  mischief  in  the  second  eye  after  couching  is  not 
great.  The  deduction  thus  drawn  from  pathological  data  is 
confirmed  by  the  author's  clinical  experience,  for,  as  far  as 
his  observations  go,  it  is  extremely  rare  to  see  the  second  eye 
lost  by  sympathetic  ophthalmia  after  this  operation. 

The  Chambers  of  the  Eye. 

The  Anterior  Chamber. — This  chamber  showed  departures 
from  the  normal  in  different  directions.  These  will  be  dealt 
with  under  separate  headings. 

i.  Scantiness  of  Contents, — One  chamber  was  quite  empty, 
due  to  the  presence  of  a  corneal  fistula  (PI.  IV.,  Fig.  23).  In  a 
number  of  cases  the  chamber  was  greatly  shallowed,  owing 
to  the  encroachment  of  the  vitreous  body  upon  it.  In  these 
the  filtering  angle  was  sealed  by  adhesion  over  a  wide  area. 
In  a  few  cases  I' iris  bombe  was  responsible  for  the  shallowing 


56  COUCHING  FOR  CATARACT 

of  the  chamber  (PL  VI.,  Fig.  34).  In  yet  others  u severe  plastic 
inflammation  had  involved  the  structures,  lying  in  and  posterior 
to  the  aqueous  chamber,  and  had  matted  them  to  the  pos- 
terior surface  of  the  cornea,  thus  almost  obliterating  the  cavity. 
This  union  had  been  so  strong  that  in  the  process  of  hardening 
the  membrane  of  Descemet  remained  adherent  to  the  organised 
exudate  beneath  it,  and  a  spurious  chamber  was  thus  formed 
lying  in  the  substance  of  the  cornea  (PI.  VI.,  Figs.  35  and  36). 

2.  Hypopyon  was  present  in  6  specimens,  and  in  one  the 
pus  was  mixed  with  blood.     The  length  of  histories  in  these 
cases  varied  from  a  matter  of  months  up  to  twenty  years. 

3.  Hyphcema. — Blood  was  present  in  the  anterior  chamber 
in    9   specimens.     In  some  of  them  it  was  fresh,  whilst  in 
others  it  was   altered   and  decolorised.     Ihe   long  histories 
given  by  a  number  of  these  cases  suggest  either  that  there 
had  been  some  recent  cause  for  haemorrhage,  or  else  that  a 
leakage  of  blood  had  been  constantly  occurring.     In  2  of  the 
eyes  the  iris  had  been  torn;  in  every  one  of  the  others  there 
was  evidence  that  severe  iritis  had  been  present. 

4.  Vitreous  in  the  Anterior  Chamber.  —  In  4  eyeballs  the 
aqueous  and  vitreous  cavities  appear  to  have  been  in  free 
communication  with  each  other,  and  filaments  of  the  vitreous 
body  can  be  traced   into  the   anterior   chamber.     In   2   of 
these  the  angle  was  widely  open,  and  in  the  other  2  it  was 
closed  by  irido-corneal  adhesions. 

5.  Lens  Matter  in  the  Chamber  (PI.  II.,  Figs.  10, 12,  and  13). 
— In  4  eyes  lens  matter  was  found  in  the  anterior  chamber. 
In  one  the  history  showed  that  a  nucleus  had  passed  freely 
backwards  and  forwards  between  the  two  chambers  (PI.  II., 
Fig.  u).     In  another  a  Morgagnian  cataract  was  wedged  in 
the  angle  of  the  chamber,  but  had  contracted  no  adhesions; 
in   the   remaining   2   the  nuclear   masses  were  firmly  fixed 
in  position  by  an  abundant  quantity  of  exudate. 

6.  Albuminous  Exudates  in  the  Anterior  Chamber. — Ihese 
were    found    in    3    cases;    few    or    no    structural    elements 
were  present.     During  life  the  contents  of  the  chamber  were 
fluid,  but  they  had  coagulated  under  the  influence  of  the 
formalin  preparation  of  the  specimens;  they  were  probably 
derived  from  the  iris  and  ciliary  body. 

The  Vitreous   Chamber. — In  the  great  majority   of  the 


PLATE  VI 

FIG.  34:  SPECIMEN  No.  in. — The  anterior  chamber  is  much  shallowed  by 
the  bulging  forward  of  the  iris  (1'iris  bombe) ;  the  pupil  is  blocked,  and 
its  edges  are  adherent  to  a  layer  composed  of  the  lens  capsule  and  the 
anterior  layer  of  the  hyaloid,  which  are  inflamed  and  matted  together. 
The  retina  is  totally  detached,  and  the  choroid  partly  so.  A  large  cyst 
can  be  seen  in  what  was  the  central  region  of  the  retina.  It  is  cut  across 
in  the  section.  (See  also  Fig.  44.) 

FIG.  35:  SPECIMEN  No.  74. — From  before  backward  we  see  (i)  the  cornea; 

(2)  a  space  which  might  be  mistaken  for  the  anterior  chamber,  but  which 
is  really  an  artificial  tear  in  the  substance  of  the  cornea  (see  Fig.  36) ; 

(3)  the  remains  of  the  iris  and  ciliary  body  matted  in  a  mass  of  exudate 
in  which  is  imbedded  (4)  what  is  left  of  the  lens.     Large  areas  of  this 
structure  have  undergone  calcification;  the  wavy  capsule  can  be  seen 
surrounding  the  lens  remnants.     Behind  this  and  continuous  with  it  is 
a  further  mass  of  exudate,  which  tightly  mats  the  folds  of  the  detached 
retina  to  the  structures  already  mentioned. 

FIG.  36:  SPECIMEN  No.  74. — A  higher  magnification  of  a  portion  of  the  pre- 
ceding section.  From  above  downward  in  the  figure  we  see  (i)  the  cornea. ; 
(2)  the  artificial  space;  (3)  the  pjpillary  margins  of  the  iris  imbedded  in 
dense  exudate.  Lining  the  lower  boundary  of  the  space  is  seen  the  greatly 
convoluted  membrane  of  Descemet,  which  has  been  torn  away  from 
its  corneal  attachments,  having  clung  more  tightly  to  the  exudate,  in 
which  the  iris  is  imbedded,  than  to  its  normal  attachments. 

FIG.  37:  SPECIMEN  No.  250.— A  large  Morgagnian  cataract  lies  imbedded  in 
a  fine  inflammatory  exudate  into  the  vitreous  cavity;  in  this  exudate 
are  many  white  inflammatory  foci.  The  retina  also  shows  many  white 
dots,  the  sclera  is  staphylomatous,  and  the  anterior  chamber  is  extremely 
shallow. 

FIG.  38:  SPECIMEN  No.  72. — -The  inflamed  optic  nerve  head  shows  a  mass  of 
exudate  occupying  the  physiological  cup  and  bulging  into  the  vitreous 
cavity.  This  mass  is  undergoing  organisation,  and  new-formed  vessels 
are  to  be  seen  in  it  at  numerous  points ;  it  was  the  apical  end  of  a  conical 
mass  which  represented  the  infiltrated  and  shrunken  vitreous  body. 
Notice  the  pull  of  the  roots  of  the  mass  on  the  edges  of  the  physiological 
cup. 

FIG.  39.:  SPECIMEN  No.  199. — The  conical  mass  occupying  the  vitreous  cavity 
has  here  undergone  a  high  degree  of  organisation,  especially  towards 
its  apex  at  the  optic  nerve  and  in  the  neighbourhood  of  the  ora  serrata. 
The  canal  of  Stilling  is  probably  indicated  by  the  white  irregular  lines 
seen  in  the  centre  of  the  cone.  The  pupil  is  blocked  with  dense  exudate 
which  fuses  with  that  of  the  cone ;  the  contraction  of  the  latter  has  com- 
pletely detached  the  retina  from  its  bed, 


PLATE    VI. 


FIG.  34  (No.  in).  —  Left  eye,  upper  half. 


FIG.  35l(No.  74). — Microscopic  section, 
low  power. 


FIG.  36  (No.  74). —  Microscopic  section, 
higher  power. 


FIG.  37  (No.  250).— Rig-ht  eye,  lower  half. 


FIG.  38  (No.  72). —  Microscopic  section, 
low  power. 


FIG.  39  (No.  199).— Right  eye,  lower  half. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  59 

eyeballs  under  examination,  it  was  observed  that  the  vitreous 
body  had  become  detached  and  shrunken,  and  that  its  rem- 
nants showed  distinct  signs  of  infiltration,  and  often  of  organisa- 
tion. The  appearances  observed  in  the  various  cases  fall 
naturally  under  a  number  of  headings :  (i)  Very  slight  evidence 
of  vitreous  structure  is  discernible  (PI.  II.,  Fig.  14).  (2)  Filmy 
masses  are  present  in  the  chamber  (PI.  II.,  Fig.  15).  These 
either  (a)  are  confined  to  the  anterior  portion  of  the  chamber, 
or  (b}  take  the  form  of  a  cone  with  its  apex  at  the  nerve  head, 
and  its  base  in  the  neighbourhood  of  the  ora  serrata  and  ciliary 
body.  (3)  Masses  are  present  which  give  the  impression  of 
being  freely  infiltrated  with  inflammatory  material,  either 
throughout  their  substance  (PI.  III.,  Fig.  16)  or  in  isolated  foci 
(PI.  VI.,  Fig.  37) ;  these  may  be  divided  into  the  same  subgroups, 
(a)  and  (b),  as  those  under  the  previous  heading.  (4)  A  distinct 
fibrous  organisation  is  noticeable  in  the  conical  masses,  which 
represent  the  detached  and  shrunken  vitreous  (PI.  III.,  Fig.  17). 
(5)  No  detail  is  discernible  (PI.  III.,  Fig.  19),  owing  to  the  fact 
that  the  retina  has  become  detached  and  inextricably  matted 
with  the  one-time  vitreous  contents,  and  with  the  iris  and 
ciliary  body. 

There  are  certain  preliminary  points  which  we  must  first 
settle : 

i.  There  is  no  essential  difference  between  the  cases  in 
which  there  is  a  definite  cone  of  filmy  or  infiltrated  membrane 
reaching  from  the  optic  nerve  head  to  the  ciliary  body,  and 
those  in  which  deposits  of  a  similar  nature  are  found  confined 
to  the  anterior  portion  of  the  vitreous  chamber.  The  grounds 
for  this  statement  are  as  follows:  (a)  An  examination  of  the 
more  complete  specimens  of  conical  exudate  shows  that  the 
membrane  becomes  very  slender  as  the  nerve  head  is  approached , 
and  it  is  obvious  that  very  little  violence  would  be  required 
to  break  this  delicate  thread  across,  and  so  to  allow  the  whole 
membrane  to  be  gathered  up  by  its  own  elasticity  towards  its 
large  and  strong  anterior  attachments,  (b)  There  is  strong 
evidence  in  a  number  of  the  specimens  of  this  series  to  show 
that  the  contraction  of  the  shrinking  inflammatory  material 
within  the  globes  takes  place  with  such  force  as  might  easily 
suffice  to  break  across  the  slender  nerve  attachment  of  some 
of  these  cones,  (c)  It  is  obvious  that  in  not  a  few  cases  the 


60  COUCHING  FOR  CATARACT 

tapering  apex  of  a  conical  exudate  is  likely  to  be  cut  across 
during  section  of  the  globe,  or  broken  across  during  subsequent 
manipulations,  (d)  Specimens  in  which  the  exudates  pre- 
sented a  definite  conical  shape,  when  they  were  first  cut  in 
India,  have  arrived  in  this  country  transformed  during  the 
voyage  into  the  similitude  of  those  in  which  the  exudate  is 
loosely  gathered  into  the  fore  part  of  the  vitreous  chamber; 
the  apex  of  the  cone  had  been  broken  off  at  the  nerve  head, 
and  the  exudate  had  moved  forward  by  virtue  of  its  own  elas- 
ticity toward  the  anterior  attachments  of  the  mass.  Taking 
all  these  points  into  consideration,  we  may  conclude  that 
in  all  the  eyeballs  which  present  the  appearance  of  shrunken 
vitreous  the  structure  was  originally  conical  in  form,  and 
that  departures  from  that  shape  are  merely  artefacts.  Stress 
is  laid  on  this  point,  because  in  a  number  of  the  globes  the 
appearances  present  suggest  that  the  exudate  is  poured  out 
from  the  ciliary  body,  and  is  confined  to  the  neighbourhood 
of  that  structure.  We  believe  such  an  interpretation  to  be 
quite  erroneous,  and  to  be  founded  on  the  observation  of 
artefacts. 

2.  Is  this  appearance  of  a  shrunken  vitreous  body  de- 
finitely pathological  ?  The  answer  is  in  the  affirmative,  for 
the  following  reasons:  (a)  All  these  globes  were  treated 
alike,  being  dropped  into  5  per  cent,  formalin  solution  on 
removal,  and  kept  there  till  frozen  and  cut.  (b)  Normal 
eyeballs  treated  in  this  way  present  no  such  evidence  of  de- 
finite vitreous  structure,  (c)  Every  grade  can  be  traced 
in  the  series  before  us,  between  the  appearance  of  delicate 
filmy  membranes  in  the  vitreous  and  the  presence  of  firmly 
organised  structures,  (d)  Though  it  is  very  difficult  to  ex- 
amine these  exudates  satisfactorily  under  the  microscope, 
there  are  a  large  number  of  specimens  which  definitely  show 
evidence  of  an  inflammatory  exudation,  strengthening  and 
thickening  the  vitreous  body.  In  not  a  few  of  these  the 
anterior  hyaloid  membrane  (the  term  is  used  in  a  non-com- 
mittal sense)  is  definitely  thickened  and  infiltrated  with  in- 
flammatory materiai(Pl.  III.,  Fig.  20).  The  conclusion  arrived 
at  is  that  these  widely  varying  evidences  of  structural  alteration 
in  the  vitreous  body  are  to  be  interpreted  as  due  to  the  penetra- 
tion of  the  hyaloid  by  inflammatory  material  of  chemotaxic 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  61 

origin,  and  to  the  subsequent  organisation  of  that  infiltration. 
(e)  There  still  remains  the  clinical  evidence.  The  author 
was  increasingly  reluctant,  as  his  Indian  experience  accumu- 
lated, to  remove  lenses  which  had  been  couched.  It  was  not 
that  vitreous  escaped,  but  that  the  results  of  operation  were 
usually  poor,  and  that  the  blame  of  the  lost  sight  was  then  apt 
to  be  most  unfairly  ascribed  to  the  extraction  operation. 
In  view  of  the  frequent  occurrence  of  vitreous  changes,  this 
failure  to  help  the  patients  is  easily  explained.  Major  Kirk- 
patrick  has  taken  a  different,  and  possibly  a  more  generous, 
view  of  the  position,  and  has  removed  a  number  of  these 
couched  lenses.  His  evidence  is  of  extreme  interest  in  the  light 
of  our  recent  pathological  findings;  he  has  been  "  struck  by 
the  rarity  of  vitreous  escape  even  after  a  fairly  extensive 
investigation  with  a  spoon  "  in  extracting  couched  lenses. 
He  adds : 

"  I  have  noticed  that  the  vitreous  body  becomes  shrunken 
and  extraordinarily  tough,  so  much  so  that  when  an  eye  is 
excised  (either  for  glaucoma  or  for  iridocyclitis  following 
Mahomedan  operation),  the  whole  globe  can  be  held  up  by  a 
strabismus  hook  transfixing  the  vitreous,  though  the  latter 
appears  perfectly  clear.  The  vitreous  undoubtedly  does 
undergo  shrinkage,  and  leaves  a  large  space,  which  is  occupied 
by  aqueous." 

Straub*  has  described  some  experiments  which  he  made  on 
animals,  in  the  course  of  which  he  injected  pathogenic  organisms 
either  into  the  vitreous  or  into  the  ciliary  body.  The  result 
varied  according  to  the  part  infected,  and  the  poisoned  area 
attracted  leucocytes  by  chemotaxis  to  itself.  Particular 
interest  attaches  to  the  following  of  his  findings:  (i)  The  optic 
nerve  head  was  swollen  and  filled  up  with  leucocytes;  (2)  there 
was  evidence  "  that  the  lymph  current  of  the  vitreous  goes  by 
the  optic  nerve,  and  that  chemotaxic  substances  are  brought 
by  this  current  from  the  granuloma  (the  artificial  infection) 
to  the  nerve  " ;  (3)  the  leucocytes  found  in  the  vitreous  showed 
the  way  from  the  granuloma  to  the  cup  of  the  optic  nerve— 
they  were  seated  on  thin  membranes,  and  most  of  them  were 
heaped  together  in  small  dots;  (4)  aggregations  were  found 

*  "The  Pathology  of  Dust-like  Bodies  in  the  Vitreous,"  etc.,  Trans,  of  the 
O-S.  of  the  U.K.,  1912,  xxxii.  60. 


62  COUCHING  FOR  CATARACT 

on  the  walls  of  the  cavities  of  the  eye  (on  the  cornea,  on  the 
retina,  on  the  lens  capsule,  etc.),  attracted  there,  in  Straub's 
opinion,  by  a  chemotaxic  action. 

In  the  experiments  above  considered,  which  were  very 
limited  in  number,  an  effort  was  made  to  localise  the  infec-- 
tion  to  one  or  other  part  of  the  eye,  and  to  work  with  a  virus 
(tubercle  bacilli)  which  was  comparatively  constant  in  its 
toxicity. 

What  Straub  did  with  a  few  eyes  has  been  done  in  the 
series  now  before  us,  by  the  Indian  coucher,  in  fifty-four. 
The  interest  of  the  experiments  is  heightened  by  the  fact  that, 
whereas  in  the  Dutch  experiments  the  toxicity  of  the  virus 
was  kept  as  constant  as  possible,  in  the  Indian  ones  it  varied 
from  that  of  organisms  which  took  many  years  to  destroy  the 
sight  to  that  of  one  which  at  once  produced  a  fulminating 
panophthalmitis.  One  point  more:  The  Indian  operator 
made  no  effort  to  confine  his  procedure  (and  with  that  procedure 
went  infection)  to  any  one  structure;  sometimes  he  attacked 
the  lens  from  in  front,  and  in  doing  so  he  often  primarily 
injured  the  iris,  but  may  have  spared  the  vitreous  chamber; 
sometimes  he  entered  through  the  ciliary  body  or  through 
the  choroid,  opening  up  the  hyaloid  cavity  in  doing  so.  His 
want  of  skill  and  the  slenderness  of  his  anatomical  know- 
ledge made  him  catholic  in  the  damage  he  inflicted,  but  running 
through  his  work  is  the  trail  of  septic  infection  of  the  eyeball 
by  penetrating  wounds.  The  result  is  that  he  has  provided 
us  with  a  large  material  of  extraordinary  interest  in  the  study 
of  the  problem  which  Straub  started  on. 

The  Filmy  Masses  in  the  Vitreous  Chamber. — As  has  already 
been  stated,  the  contents  of  the  vitreous  chamber  in  these 
specimens  vary  from  thin  gauzy  films,  which  can  only  be  de- 
tected by  careful  search,  up  to  thick  masses  which  strike  the 
eye  as  soon  as  the  specimen  is  looked  at. 

It  is  not  easy  to  obtain  a  view  of  these  exudates  in  section, 
but  nevertheless  they  appear  in  a  considerable  number  of 
the  microscopic  specimens,  and  their  character  is  always  the 
same;  they  consist  of  more  or  less  structureless  masses  with 
blood-cells  and  leucocytes  imbedded  in  their  substance.  In 
fact,  they  would  seem  to  be  identical  with  the  membrane 
spoken  of  by  Straub  as  harbouring  the  leucocytes  which  gave 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  63 

rise  to  dust-like  and  other  opacities  of  the  vitreous  in  his  ex- 
perimental cases.  At  a  later  stage,  or  perhaps  in  cases  where  the 
inflammation  has  been  of  a  more  plastic  character,  a  distinct 
fibrillation  of  the  exudate  can  be  seen,  and  there  may  even  be 
evidence  of  a  definite  fibrous  tissue  formation.  If  we  confine 
our  attention  for  the  moment  to  those  eyeballs  in  which  the 
exuded  mass  is  devoid  of  structure  in  the  anterior  portion  of 
the  cone,  we  shall  find  that,  on  tracing  it  back  toward  the  apex 
by  which  it  is  attached  to  the  optic  nerve,  it  becomes  more  highly 
organised  and  more  richly  cellular,  whilst  fibrillation  and  fibrous 
tissue  formation  make  their  appearance.  The  same  thing, 
though  in  a  lesser  degree,  may  be  observed  in  the  neighbourhood 
of  the  ciliary  body,  doubtless  due  to  the  presence  of  a  plastic 
exudate  derived  from  that  structure. 

An  examination  (PI.  VI.,  Fig.  38)  of  the  optic  nerve  and  of  the 
exudate  attached  to  it  reveals  the  following  features:  (i)  The 
nerve  head  is  congested,  and  its  vessels  stand  out  in  prominent 
relief.  (2)  There  is  a  considerable  effusion  of  leucocytes  in 
the  neighbourhood  of  these  vessels.  .  (3)  A  mass  of  exudate 
fills  up  and  projects  from  the  optic  nerve  cup,  whether  this 
latter  is  physiological  or  glaucomatous.  This  mass  is  clearly 
contracting,  and  thereby  pulling  on  the  tissue  which  lines  the 
edges  of  the  cup.  (4)  Along  the  centre  of  the  projecting 
exudate  are  to  be  seen  (a)  an  abundance  of  mononuclear 
cells;  (b)  the  commencement  of  a  fibrous  tissue  formation;  and 
(c)  a  new  formation  of  bloodvessels. 

The  appearances  above  enumerated  would  indicate  that 
we  have  to  do  with  an  inflammation  of  the  optic  nerve, .which 
had  been  induced  by  chemotaxic  substances  brought  thither 
along  Stilling' s  canal.  Such  an  idea  is  not  a  new  one.  It  was 
suggested  by  Straub  in  order  to  explain  the  optic  neuritis  he 
found  in  his  two  cases  of  experimental  inoculations  of  the 
ciliary  body,  and  it  also  enjoys  provisionally  the  support  of 
Fuchs's*  authority.  The  idea  that  part  of  the  lymph  of  the 
eye  passes  backward  along  a  passage  corresponding  to  the 
central  hyaloid  canal  is  not  generally  accepted,  and  rests 
largely  on  inference  from  the  observation  of  pathological 
specimens.  It  would  be  difficult,  however,  for  anyone  who 

*  Fuchs:  "Textbook  of  Ophthalmology''   Duanc,    fourth  edition,    1911, 
p.  16. 


64  COUCHING  FOR  CATARACT 

has  carefully  studied  this  series  to  doubt  that  such  a  flow  exists ; 
it  is,  of  course,  not  suggested  that  any  large  percentage  of  the 
lymph  travels  in  this  direction. 

A  confirmation  of  these  views  is  obtained  if  we  refer  to 
the  three  eyeballs  in  which  the  organisation  of  the  cone  of 
exudate  into  the  vitreous  has  attained  the  highest  development. 
We  notice  in  these  how  extremely  far  this  process  of  organisa- 
tion has  been  carried  in  the  apex  of  the  cone,  where  it  is  re- 
presented as  a  well-defined  opaque  cord  (PI.  VI.,  Fig.  39  ; 
and  PI.  III.,  Fig.  17).  In  one  of  the  three  a  fibrous  band, 
presumably  the  remains  of  the  canal  of  Stilling,  is  clearly 
seen,  whilst  in  the  two  others  the  existence  of  this  structure 
is  at  least  indicated.  It  is  possible  that  in  the  first-named 
a  congenital  peculiarity  exaggerated  the  distinctness  of  the 
appearance. 

The  Retina. 

Detachment  of  the  retina  occurred  in  38  of  the  54  globes 
(70-38  per  cent.),  and  was  absent  in  16  (29-62  per  cent.). 
It  was  partial  and  ill-marked  in  5  (9-25  per  cent.),  extensive 
in  9  (16-68  per  cent.),  and  complete  in  24  (44-44  per  cent.). 
The  ocular  tension  was  above  normal  in  n  out  of  the  16, 
which  presented  no  detachment,  but  in  only  6  out  of  the 
remaining  38  ;  it  was  below  the  normal  in  13  of  the  24  globes 
with  complete  detachment,  and  above  it  in  3  of  them.  In 
the  very  great  majority  of  the  eyes  the  detachment  of  the 
retina  was  undoubtedly  due  to  traction  from  within.  The 
sequence  of  events  is  plain  from  a  study  of  the  whole  series. 

At  the  operation  there  was  an  infection  of  the  coats  of  the 
eye,  and  also  of  the  vitreous  chamber  from  without;  this  led 
to  the  formation  of  inflammatory  material  within  the  vitreous 
chamber;  adhesions  took  place  between  these  new-formed 
membranes  and  the  retina ;  finally  the  shrinkage  of  the  organis- 
ing inflammatory  material  tore  the  retina  from  its  bed.  Every 
step  of  the  process  can  be  traced  either  in  microscopic  sections  or 
in  the  naked-eye  specimens.  The  earliest  possible  stage  is  seen 
under  the  microscope  in  sections  of  an  eyeball  (No.  37) ,  where 
in  the  neighbourhood  of  the  ora  serrata  the  shrinkage  of  the 
exudate  within  the  vitreous  chamber  has  just  begun  to  lift 
the  retina  from  its  bed.  The  individual  points  of  attachment 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  65 

between  the  inflammatory  membrane  and  the  retina  are 
beautifully  illustrated.  The  ultimate  stage  of  the  process  is 
to  be  found  in  those  cases  in  which  the  retina  is  not  merely 
totally  detached,  but  has  shrunk  posteriorly  into  a  stick- 
like  form  (PI.  III.,  Fig.  19,  and  PI.  IV.,  Fig.  25),  whilst  it 
opens  out  anteriorly  into  a  mass  in  which  the  iris,  the 
ciliary  body,  the  lens,  the  remains  of  the  vitreous,  and  the 
retina  are  inextricably  matted  and  tangled.  When  sections 
of  such  specimens  are  examined  under  the  microscope,  their 
leading  feature  is  the  evidence  of  severe  plastic  iridocyclitis, 
with  the  formation  of  abundant  cicatricial  tissue,  which 
mats  all  the  parts  together  and  severely  distorts  the  normal 
anatomical  arrangement.  The  retina  is  dragged  forward  from 
the  neighbourhood  of  the  ora  serrata  over  the  ciliary  body, 
whilst  elsewhere  it  is  thrown  into  abundant  folds  and  com- 
pletely separated  from  its  normal  attachments.  A  pseudo- 
cystic  condition  is  thus  produced,  the  apparent  cysts  being 
formed  by  the  elaborate  folding  of  the  membrane  (PI.  III., 
Fig.  19,  and  PL  V.,  Fig.  31).  These  may  be  small  and  slit- 
like,  or  may  be  large  and  round,  so  simulating  the  appearance 
of  true  cysts.  In  front  of  the  retinal  mass,  lens  fragments  and 
capsule  are  seen  in  a  number  of  the  specimens  entangled  in 
the  scar-4issue.  As  has  already  been  said,  all  grades  can  be 
traced,  from  the  slightest  detachments  up  to  those  we  have 
just  been  describing.  The  greater  or  less  degree  of  separa- 
tion of  the  retina  met  with  in  the  different  globes  is  doubtless 
in  part  a  question  of  time,  but  it  is  also,  and  probably  to  a 
much  larger  extent,  one  of  the  character  and  grade  of  the 
inflammatory  process  excited  in  the  eyeball.  The  more 
plastic  the  type  of  inflammation  and  the  more  intense  the 
process  is,  the  greater  will  be  the  measure  of  ultimate  cicatrisa- 
tion, always  provided  that  the  inflammation  is  not  intense 
enough  to  result  in  suppuration. 

There  are  several  different  ways  in  which  the  exudate 
which  forms  within  the  vitreous  chamber  may  be  placed 
in  a  favourable  position  for  the  production  of  retinal  detach- 
ment. 

i.  The  first  of  these  is  illustrated  by  each  of  those  globes 
(Nos.  44  and  72)  in  which  the  site  of  a  wound  of  the  retina 
forms  the  point  of  connection  between  that  membrane  and 

5 


66         COUCHING  FOR  CATARACT 

the  inflammatory  exudate  lying  in  the  vitreous  cavity  (PL  V., 
Fig-  3°)-  The  traumatic  infection  of  the  retina  served  to  attach 
the  vitreous  exudate  to  its  walls,  and  thus  paved  the  way  for 
the  separation  of  the  membrane.  In  one  of  these  cases  (No.  44) 
a  longitudinal  fold  was  detached,  whilst  in  the  other  (No.  72) 
the  detachment  was  broad  and  shallow. 

2.  In  the  second  method  also,  it  is  necessary  to  postulate 
an  infection  of  the  retina  before  that  membrane  could  have 
contracted  adhesions,  either  localised  or  widespread,  to  the 
neighbouring   vitreous   exudate.     Once,   however,   the   virus 
was  planted  within  the  hyaloid  chamber,  it  probably  diffused 
itself  widely,  and  by  means  of  chemotaxis  set  up  an  inflam- 
mation of  the  retina;  evidences  of  such  a  retinitis  abound 
in  many  of  the  specimens.     Attachments  between  the  vitreous 
exudate  and  the  retina  having  been  thus  formed,  the  con- 
traction of  the  former  would  naturally  lead  to  the  separation 
of  the  latter  from  its  choroidal  bed. 

3.  In  a  few  of  the  globes  the  contracting  membrane  is 
merely  an  infiltration  and  thickening  of  the  anterior  layer  of 
the  hyaloid.     It  is  well  known   that  the  vitreous  body  is, 
under  normal  conditions,  more  firmly  attached  to  the  retina 
in  the  neighbourhood  of  the  ora  serrata  than  it  is  elsewhere; 
it   is   therefore   obvious   that   an   inflammatory   contracting 
membrane  in  the  anterior  part  of  the  vitreous  will  pull  through- 
out its  whole  circumference  on  the  retina  in  its  neighbourhood, 
effecting   a   detachment   over   a   very   wide   area    (PL    III., 
Fig.  20).     This  is  just  what  we  see  happening  in  the  globes 
we  are  now  discussing. 

4.  In  a  number  of  the  specimens  it  can  be  clearly  seen 
that  the  bands,  which  drag  upon  the  retina,  radiate  from  the 
remains   of  lens  masses,   which   are   themselves  encased   in 
inflammatory  tissue,  and  are  bound  thereby  to  the  iris  and 
ciliary  body  in  their  neighbourhood.     Such  bands  appear  in 
some  cases  to  lie  in  the  substance  of  the  retina  itself  (PL  IV., 
Fig.  24) ;  in  others  they  are  situate  in  the  vitreous  and  present 
the  form  of  membranous  sheets,  separated  from  the  subjacent 
retina  only  by  narrow  spaces,  and  finding  attachment  to  it  in 
the  neighbourhood  of  the  equator  (Nos.  117  and  170).     The 
characteristic  of  these  cases  would  appear  to  be  that  the  dis- 
located lens  is  in  them  the  principal  focus  of  sepsis  within  the 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  67 

eye.  The  point  is  of  interest,  since  some  of  them,  at  least, 
represent  ruptured  Morgagnian  cataracts;  for  there  is  reason 
to  believe,  on  clinical  grounds,  that  the  liberation  of  Morgag- 
nian fluid  within  the  eye  is,  sometimes  at  least,  productive  of 
considerable  irritation  to  the  surrounding  parts. 

There  are  two  globes  in  the  collection  in  which  the  exudate 
within  the  hyaloid  cavitj^,  converted  into  organised  fibrous 
tissue,  is  obviously  tearing  the  retina  from  its  bed  in  the 
course  of  its  contraction.  A  very  interesting  feature  of 
these  eyeballs  is  that  in  each  of  them  an  opaque  band  which 
strongly  suggests  Stilling's  canal  can  be  traced  forward  from 
the  optic  nerve  head  (PL  VI.,  Fig.  39). 

In  many  of  the  specimens  an  abundant  subretinal  exudate 
is  present.  In  the  long-standing  ones,  with  complete  detach- 
ment of  the  retina,  this  effusion  fills  up  the  whole  of  the  space 
between  the  retina  and  the  choroid.  When  the  latter  mem- 
brane is  also  detached,  a  further  exudate  of  similar  appearance 
is  seen  between  it  and  the  sclera.  Owing  to  the  action  of  the 
formalin,  the  very  firm  coagulation  of  the  long-standing  effu- 
sions gives  the  eyes  a  solid  and  very  characteristic  appearance 
(PI.  III.,  Fig.  19) ;  the  half-globes  look  like  sections  of  marbles 
made  of  fissured  and  clouded  glass.  In  earlier  cases  the  effused 
mass  is  much  less  firm,  but  is  whiter  and  more  opaque,  with  a 
tendency  to  present  a  flocculent  appearance.  The  question 
that  naturally  presents  itself  is,  whether  these  effusions  were 
the  cause  or  the  result  of  the  retinal  detachment.  The  pres- 
ence of  the  inflammatory  exudate  within  the  vitreous,  with 
which  we  have  already  dealt,  provides  such  a  satisfactory  ex- 
planation of  the  detachments  of  the  retina  throughout  this 
series,  that  it  seems  unlikely  that  the  effusions  in  question, 
whether  subretinal  or  subchoroidal,  play  any  causative  part 
whatever. 

We  must  place  in  quite  a  different  category  the  cases, 
four  in  number,  in  which  the  effused  fluid  consisted  of  blood. 
The  source  of  the  haemorrhage  in  these  cases  is  different  from 
that  which  is  met  with  when  the  pressure  within  an  eye  is 
suddenly  reduced  by  the  operative  opening  of  the  globe. 
In  the  latter  case  it  is  the  large  choroidal  vessels  which  give 
way,  and  the  haemorrhage  is  subchoroidal,  whereas  in  the  four 
cases  under  review  the  bleeding  was  subretinal  in  one  (No.  157), 


68  COUCHING  FOR  CATARACT 

into  the  vitreous  chamber  alone  in  one  (PI.  VII.,  Fig.  40),  and 
into  both  the  vitreous  chamber  and  the  subretinal  space  in  two. 
The  haemorrhage  into  the  vitreous  chamber  was  probably  due 
to  injury  to  the  retinal  vessels  by  the  coucher's  instrument, 
though  it  is  possible  that  blood  may  have  found  its  way  through 
the  retinal  cut  from  choroidal  vessels  divided  at  the  time.  The 
subretinal  haemorrhage  probably  escaped  from  the  severed 
branches  of  the  smaller  choroidal  vessels.  The  fact  that  in 
no  case  was  a  large  subchoroidal  haemorrhage  present  would 
indicate  that  the  large  choroidal  vessels  were  tough  enough 
to  escape  injury,  being  probably  pushed  aside  by  the  com- 
paratively blunt  instrument  the  coucher  used.  In  one  eye- 
ball (No.  157)  large  cholesterine  crystals  were  seen  shining 
on  the  cut  surface  of  the  sanguineous  mass.  A  similar  pheno- 
menon was  observed  in  the  case  of  one  of  the  albuminous 
effusions  above  spoken  of. 

It  remains  to  deal  with  a  rare  cause  of  detachment  of  the 
retina  or  of  the  retina  and  choroid — viz.,  the  application  of 
direct  violence  at  the  time  of  operation.  This  is  best  exem- 
plified in  the  two  globes  in  which  the  cataract  was  thrust 
through  and  behind  the  retina,  by  the  coucher's  instrument, 
at  the  time  of  operation  (PL  IV.,  Fig.  22).  It  is  also  beauti- 
fully illustrated  by  specimen  No.  72,  in  which  the  retina  and 
choroid  were  carried  in  front  of  the  coucher's  instrument 
before  the  latter  succeeded  in  perforating  them  (PI.  V., 
Fig.  30).  The  dislocation  thus  produced  proved  permanent. 

Dots  on  the  Retina. — A  striking  feature  of  the  series  of 
specimens  before  us  is  the  presence  of  numerous  dots  on  the 
retina.  These  are  to  be  seen  in  16  cases,  and  doubtfully  in 
a  seventeenth.  In  at  least  one  other,  similar  dots  are  present 
on  the  choroid  and  on  the  posterior  surface  of  the  iris  (PI.  V., 
Fig.  28).  We  therefore  find  this  peculiar  appearance  in  one 
case  in  every  three;  but  this  is  far  from  representing  what  is 
probably  its  real  relative  frequency,  for  in  24  of  the  globes 
the  retina  was  totally  detached,  and  it  was  therefore  impos- 
sible to  say  whether  there  were  dots  present  on  it  or  not. 
If  we  put  these  24  to  one  side,  we  find  that  the  dots  were 
certainly  present  in  16  out  of  30 — that  is,  in  well  over  50  per 
cent.  If  we  include  the  other  2  cases  above  alluded  to,  the 
figure  rises  to  60  per  cent. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  69 

In  some  of  the  specimens  the  dots  are  so  large  that  they 
could  scarcely  be  missed  under  a  careful  naked-eye  examina- 
tion (PI.  III.,  Fig.  1 8),  whilst  in  others  they  were  only  dis- 
covered when  highly  magnified  photographs  of  the  eyeballs 
were  thrown  on  a  screen  (PI.  III.,  Fig.  17).  They  could, 
however,  be  found  easily  with  a  loupe  once  their  presence 
was  known.  The  variation  in  different  specimens  was  not 
confined  to  size;  some  of  the  dots  were  white,  others  were 
a  pale  grey,  and  a  few  were  bright  and  shiny.  Again, 
some  of  them  appeared  much  more  sharply  defined  than 
others. 

It  was  at  first  thought  that  manifestations  so  distinct 
under  slight  magnification  would  yield  very  definite  appearances 
under  the  microscope;  but,  on  the  contrary,  much  difficulty 
has  been  experienced  in  deciding  the  nature  of  the  changes 
which  have  given  rise  to  this  phenomenon. 

One  of  the  first  points  noticed  was  that  the  dots  were  found 
almost  exclusively  in  long-standing  cases.  This  of  itself 
would  appear  to  indicate  that  their  cause  was  to  be  sought 
in  some  degenerative  process;  but  a  closer  analysis  of  the 
histories  revealed  a  probable  fallacy  in  such  an  argument, 
since  a  number  of  the  eyes  had  had  good  vision  for  a  long 
period  after  operation,  and  had  eventually  succumbed  to  a 
fresh  inflammatory  invasion,  or  possibly  to  a  more  severe 
recrudescence  of  a  septic  condition  implanted  at  the  time  of 
operation. 

On  examination  of  a  number  of  specimens,  three  distinct 
appearances  have  been  found,  any  one  of  which  might 
presumably  account  for  the  dots  seen  with  the  naked 
eye. 

i.  In  some  of  the  globes  a  proliferative  retinitis  can  be 
found  along  certain  of  the  vessels  (PI.  VII.,  Fig.  41).  These 
consist  in  section  of  masses  of  mononuclear  leucocytes  sur- 
rounding the  vessel  wall,  and  tending  to  make  their  way  to 
the  inner  surface  of  the  retina.  It  might  be  thought  that  such 
a  change  would  produce  lines  rather  than  dots,  and  that  those 
lines  would  run  along  the  course  of  the  vessels;  but  there  are 
two  features  which  make  this  doubtful:  (a)  Even  under  the 
same  field  some  of  the  vessels  appear  quite  healthy  on  section, 
whilst  others  show  distinct  masses  of  proliferation ;  and  (b)  along 


70  COUCHING  FOR  CATARACT 

the  course  of  a  vessel  cut  obliquely  one  may  find  the  prolifera- 
tive  exudate  confined  to  one  part  of  its  course,  the  rest  being 
comparatively  free. 

2.  In  the  neighbourhood  of  some  of  the  inflamed  retinal 
vessels  above  spoken  of,  one  finds  on  the  surface  of  the  retina 
what  appear  to  be  free  collections  of  mononuclear  cells  (PI.  VII., 
Fig.  42).    These  are  apparently  of  the  same  nature  as  the  dots 
described  by  Straub  on  the  posterior  surface  of  the  cornea  and 
in  the  vitreous  body.    It  will  be  remembered  that  he  attributed 
them  to  chemotaxic  action.     It  would  appear  not  improbable 
that  the  same  explanation  holds  for  these  retinal  dots.     It 
is  of  interest  that,  though  they  occur  in  cases  of  long  standing, 
the  history  of  a  subsequent  inflammation,  destructive  to  vision 
is  of  a  much  later,  and  indeed,  of  a  comparatively  recen 
date.     The  presence  of  such  exudative  masses  would  then  be 
easily  explained. 

3.  The   grouping    of   these    dots    varies   considerably   in 
different  specimens,  but  does  not  lend  much  colour  to  the  idea 
that  they  are  vascular  in  origin,  for  in  some  at  least  of  the  eyes 
they  certainly  do  not  follow  the  course  of  the  vessels.     On  the 
other  hand,  in  a  few  of  the  eyeballs  there  is  a  massing  of  these 
dots  in  the  neighbourhood  of  the  ora  serrata,  which  is  in  itself 
suggestive  of  a  degenerative  process,  since  this  is  the  area  of 
lowest  circulatory  activity,  inasmuch  as  this  region  is  supplied 
by  the  ultimate  twigs  of  the  retinal  vessels.     This  observation 
gathers  interest  from  the  fact  that  in  quite  a  number  of  these 
specimens  it  is  possible  to  demonstrate  the  presence  of  small 
cysts  in  the  walls  of  the  retina  (PL  VII.,  Fig.  43).    These  cysts 
are  produced  by   the  coalescence  of   cedematous  spaces  in 
degenerative  areas.     All  stages  of  the  process  can  be  traced 
in  different  specimens  of  the  series  before  us.     Such  cysts  are 
only  likely  to  be  met  with  in  long-standing  cases  in  which  the 
degenerative  processes  have  had  time  for  full  play. 

Inasmuch  as  these  retinal  dots  are  found  in  the  cases  in 
which  the  retina  is  still  in  its  normal  position,  it  would  seem 
probable  that  a  careful  clinical  search  should  reveal  their 
presence  in  living  eyes  now  that  their  existence  is  established 
pathologically.  It  is  a  point  which  should  repay  the  study  of 
surgeons  who  are  practising  where  couching  is  commonly 
resorted  to,  and  especially  in  India. 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  73 

Macroscopic  Cysts  of  the  Retina. — It  remains  to  speak  of 
larger  cysts  of  the  retina  which  can  be  recognised  by  the  naked 
eye.  It  has  already  been  mentioned  that,  in  those  cases  in 
which  this  membrane  has  been  found  to  be  tightly  folded  on 
itself,  a  pseudo-cystic  condition  is  thereby  produced;  the 
cavities  of  these  false  cysts  are  merely  shut-off  portions  of  the 
original  vitreous  chamber.  Of  a  quite  different  nature  are 
the  true  cysts  of  the  retina,  three  examples  of  which  are  to  be 
found  in  this  collection.  In  one  (PI.  II.,  Fig.  12)  a  narrow 
slit-like  cyst  is  seen  in  the  outer  layers  of  the  detached  retina 
at  its  lower  part.  In  the  second,  a  whole-section  of  the  globe 
shows  a  large  cyst  occupying  the  central  region,  the  macular 
area  forming  a  portion  of  its  wall  (PL  VII. ,  Fig.  44).  Lastly,  in 
the  third  a  large  round  cyst  can  be  seen  to  the  temporal 
side.  A  point  of  interest  in  connection  with  this  specimen  is 
that  it  shows  both  true  and  false  retinal  cysts  (PI.  III., 
Fig.  19,  and  PI.  V.,  Fig.  31). 

The  Choroid. 

It  remains  to  add  a  few  words  to  what  has  already  been 
said  about  this  membrane.  The  great  majority  of  the  changes 
we  have  found  in  it  are,  clearly,  to  be  attributed  to  the  effects 
either  of  hypertony  or  of  hypotony  of  the  eye;  they  do  not, 
therefore,  differ  from  similar  appearances  found  under  the  same 
conditions  generally. 

Compared  with  detachments  of  the  retina,  those  of  the 
choroid  are  rare  in  this  series.  In  one  instance,  already 
mentioned,  the  two  membranes  had  been  displaced  together 
by  the  instrument  used  in  couching  (PL  V.,  Fig.  30). 
In  another,  in  which  severe  inflammation  had  occurred,  the 
retina  and  choroid  had  adhered  to  each  other,  and  had  been 
detached  as  one  sheet  by  the  contraction  of  an  exudate,  which 
lay  in  the  neighbourhood  of  the  iris  and  ciliary  body  and  in 
the  front  part  of  the  vitreous  cavity.  In  a  number  of  other 
globes,  in  which  the  tension  was  low,  the  ciliary  body  and  the 
anterior  portion  of  the  choroid  were  found  separated  from  the 
sclera  as  far  back^as  the  line  where  the  anterior  segment  of 
the  latter  coat  was  drawn  over  the  posterior  in  the  manner 
pointed  out  by  Treacher  Collins  in  his  work  on  Hypotony 
(Trans,  of  the  O.S.  of  the  U.K.,  1917). 


74  COUCHING  FOR  CATARACT 

In  the  previous  chapter  we  have  spoken  of  an  appearance 
commonly  seen  in  successfully  couched  eyes — viz.,  an  un- 
usual distinctness  of  the  large  vessels  of  the  choroid  in  the 
ophthalmoscopic  picture.  It  is  necessary  to  insist  that  in 
such  cases  the  vessels  are  not  sclerosed ;  they  are  seen  with  un- 
usual distinctness  simply  because  the  pigment  which  usually 
hides  them  from  view  has  disappeared.  What  is  more,  a 
careful  study  of  a  number  of  these  cases  has  created  a  strong 
impression  that  the  deficiency  in  pigmentation  affects  both 
the  pigmentary  layer  of  the  retina  and  also  the  pigment  of 
the  choroid.  The  absence  of  the  former  lays  bare  what  lies 
behind  it ;  the  absence  of  the  latter  is  inferred  from  the  general 
appearance  of  pseudo-albinism.  These  findings  are  the  more 
noteworthy  by  reason  of  their  contrast  to  the  usual  deep  pig- 
mentation of  the  Indian  eye.  Some  of  our  specimens  throw 
light  on  ;this  phenomenon,  for  we  observe  in  them  two  changes : 
(i)  The  pigmentary  layer  of  the  retina  is  irregularly  thinned 
and  altered,  and  at  some  points  its  pigment  can  be  seen  mi- 
grating into  the  choroid;  (2)  the  choroidal  pigment  itself  is 
extensively  altered  in  an  irregular  manner,  being  heaped  up 
in  some  areas  and  thinned  in  others.  It  is  necessary  to  re- 
member that,  inasmuch  as  our  specimens  are  wholly  obtained 
from  the  coucher's  failures,  whilst  the  interesting  appearance 
we  are  discussing  is  best  seen  in  his  successes,  we  cannot 
expect  very  definite  results  from  our  pathological  material, 
since  the  changes  we  desire  to  study  are  there  overlaid  and 
obscured  by  those  of  pathological  processes,  such  as  hypertony, 
hypotony,  and  inflammation. 


Glaucoma. 

It  has  long  been  known  that  couching  is  frequently  followed 
by  secondary  glaucoma.  In  the  present  series  of  54  globes, 
19  of  them  showed  evidence  of  high  intra-ocular  pressure. 
This  figure  must  not,  however,  be  taken  as  a  reliable 
index  of  the  numerical  frequency  of  glaucoma  as  a  complica- 
tion of  the  operation.  On  the  one  hand,  we  must  remem- 
ber that  the  present  series  deals  with  the  failures  only,  and  that 
a  large  number  of  eyes  are  met  with  clinically  in  which  the  lens 
is  floating  free  in  the  vitreous  chamber  without  any  sign  that 


PATHOLOGICAL  ANATOMY  OF  COUCHED  EYES  75 

the  intra-ocular  tension  is  raised.  Again,  the  cases  which  go 
on  to  suppuration,  and  which  are  very  numerous,  are  excluded 
from  the  present  series  owing  to  the  fact  that  all  such  were 
eviscerated  in  order  to  avoid  the  risk  of  intracranial  sepsis. 
This  obviously  diminishes  the  total  number  of  globes  under 
consideration,  and  thereby  raises  the  apparent  percentage 
of  other  conditions,  such  as  glaucoma.  On  the  other  hand, 
it  would  be  a  mistake  to  suppose  that  out  of  these  54  globes 
only  19  had  suffered  from  secondary  glaucoma,  for  in 
24  of  them  a  complete  detachment  of  the  retina  had 
covered  up  any  evidence  which  may  at  some  time  have 
existed  of  the  presence  of  increased  intra-ocular  pressure, 
though  the  conditions  still  found  in  some  of  them  make  it  more 
than  probable  that  the  globes  were  formerly  glaucomatous. 
In  any  case,  it  leaves  us  with  the  fact  that,  out  of  30  eye- 
balls which  were  available  for  accurate  examination,  no  less 
than  19  were  glaucomatous.  In  17  of  the  19  the 
angle  of  the  anterior  chamber  was  extensively  closed,  and 
in  3  of  these  the  chamber  was  so  shallow  as  almost  to 
be  reduced  to  a  potential  slit.  The  remaining  2  are  thus 
accounted  for:  In  one  the  angle  was  open  save  for  a  small 
marginal  adhesion,  and  there  was  free  communication  be- 
tween the  aqueous  and  vitreous  chambers;  unfortunately, 
the  specimen  was  almost  spoilt  in  sectioning  it  for  the  micro- 
scope ;  in  the  second,  a  Morgagnian  lens  was  impacted  in  and 
had  blocked  the  angle  of  the  anterior  chamber. 

Returning  to  the  17  cases  in  which  the  angle  of  the 
chamber  was  closed,  and  to  certain  other  eyeballs  in  which 
it  seemed  probable  that  glaucoma  had  at  some  time  been 
present,  we  found  that  in  every  one  of  them  one  or  other  of 
the  accepted  causes  of  secondary  glaucoma  was  revealed  when 
looked  for;  in  some,  more  than  one  such  cause  was  discoverable. 
We  shall  content  ourselves  with  enumerating  these  factors. 

A  corneal  fistula,  with  evidence  of  past  anterior  staphy- 
loma,  was  present  in  one;  here  the  cause  of  the  glaucoma 
was  evidently  the  closure  of  the  filtering  angle,  which  resulted 
from  the  anterior  synechia ;  in  one  there  was  a  capsulo-corneal 
synechia  (PI.  IV.,  Fig.  24),  and  in  another  a  retino-corneal 
synechia  (PI.  IV.,  Fig.  25) ;  in  5  the  ciliary  body  was  involved 
in  the  scar;  in  6 the  dislocated  lens  pressed  extensively  on  the 


76  COUCHING  FOR  CATARACT 

iris  base  (PI.  VII.,  Fig.  45);  in  3  the  lenses,  tilted  at  right 
angles  to  their  normal  position,  pressed  the  anterior  hyaloid 
membrane  severely  back  on  the  side  of  the  dislocation,  whilst 
causing  the  vitreous  to  bulge  the  iris  forward  into  the  anterior 
chamber  on  the  opposite  side ;  in  5  the  pupil  was  blocked,  and 
in  3  of  these  1'iris  bombe  was  present ;  in  2  the  anterior  layers  of 
the  hyaloid  were  so  thickened  by  inflammatory  exudate  as  to 
suggest  that  there  was  an  abnormal  obstruction  to  the  passage 
of  fluid  across  the  membrane;  in  one  a  marked  thickening  of 
the  lens  capsule  in  the  form  of  an  after-cataract  may  possibly 
have  provided  an  obstruction  to  the  forward  passage  of  fluid 
from  the  vitreous;  lastly,  there  is  one  globe  in  which  glaucoma 
had  probably  been  present  before  the  operation,  if  one  may 
judge  from  the  history  of  the  case  and  from  the  violent  haemor- 
rhage which  followed  the  couching. 

It  has  been  suggested  that  one  of  the  causes  of  glaucoma 
after  this  operation  is  an  advance  of  the  front  part  of  the 
vitreous  body  owing  to  a  rupture  of  the  anterior  layers  of  the 
hyaloid  during  the  operation.  Without  in  any  way  denying 
that  the  suggestion  may  be  a  valid  one  in  certain  cases,  the 
impression  gained  from  a  study  of  this  series  is  that  we  need 
look  no  farther  than  the  well-recognised  causes  of  secondary 
glaucoma.  We  have  only  to  remember  that  the  trauma  in- 
flicted is  extensive  and  various,  and  that  a  greater  or  less  degree 
of  sepsis  accompanies  every  couching  in  the  hands  of  its  Indian 
exponents. 


CHAPTER    VI 

DIAGNOSIS 

THE  diagnosis  of  a  case  of  couched  cataract  presents  the 
surgeon  with  three  distinct  problems:  (i)  To  ascertain  whether 
a  couching  has  been  done  or  not;  (2)  to  discover  the  new 
position  of  the  lens  and  its  condition ;  and  (3)  to  decide  whether 
it  is  advisable  to  operate.  Only  those  who  work  in  lands, 
where  the  couching  of  cataracts  is  an  everyday  occurrence, 
will  take  a  deep  concern  in  such  questions;  but  the  subject  has 
a  scientific  interest  which  cannot  fail  to  appeal  to  any  one  who 
devotes  his  serious  attention  to  the  large  questions  of  ophthal- 
mology. 

It  might  be  thought  that  the  simple  and  obvious  way  to 
ascertain  whether  a  couching  had  been  done  would  be  to  ask 
the  patient  or  his  relatives.  In  a  large  number  of  cases  this 
is  of  course  sufficient;  but  in  India,  at  all  events,  there  are 
many  who  will  deny  the  operation  they  have  undergone. 
This  is  due  to  the  fact  that  it  is  widely  known  among  the  people 
that  the  British  surgeons  view  the  coucher  and  all  his  methods 
with  extreme  disfavour.  Patients  are  therefore  reluctant 
to  admit  having  consulted  him,  and  they  also  are  afraid  lest 
treatment  should  be  refused  them,  once  their  true  history  is 
known;  for  it  is  common  knowledge  amongst  them  that  the 
\Yestern  practitioner  is  extremely  reluctant  to  interfere  with 
an  eye  which  a  coucher  has  spoilt.  It  is  well,  therefore,  to 
consider  carefully  the  grounds  on  which  the  physical  diagnosis 
of  a  couched  lens  should  rest. 

We  will  first  consider  the  case  of  those  eyes  in  which  the 
cataract  has  been  definitely  removed  from  the  neighbourhood 
of  the  pupil.  These  present  certain  well-marked  signs :  (i)  The 
pupil  is  brilliantly  black,  and  (2)  the  plane  of  the  iris  is  flat. 
It  may  seem  strange  to  insist  upon  these  points,  but  to  the 
trained  eye  they  are  so  obvious  that  a  diagnosis  can  often 

77 


78  COUCHING  FOR  CATARACT 

be  made,  as  soon  as  the  patient  takes  his  seat  in  the  out-patient 
room,  in  front  of  the  surgeon.  The  quality  of  the  blackness 
of  the  pupil  is  difficult  to  put  into  words,  but  it  arrests  the 
attention  by  its  contrast  to  the  ordinary  appearance  of  the 
pupil  in  people  so  advanced  in  life  as  the  subjects  of  cataract 
usually  are.  The  phenomenon  is  due  to  the  whole  cataract, 
capsule  and  all,  being  thrust  away  from  the  pupillary  area,  and 
it  can  be  equally  well  seen  in  cases  which  have  undergone 
the  intra-capsular  operation.  Then,  with  regard  to  the  flatten- 
ing of  the  iris,  the  trained  eye  is  used  to  the  appearance  pre- 
sented by  the  slight  forward  convexity  of  that  membrane  as 
a  result  of  the  presence  of  the  lens  behind  it ;  whereas  the  com- 
plete removal,  not  merely  of  the  lens,  but  also  of  the  support 
of  the  suspensory  ligament,  makes  the  iris  flatten  out  in  its 
own  plane. 

On  close  inspection  we  notice  other  signs.  (3)  The  iris, 
deprived  of  the  support  of  the  lens,  is  often  tremulous.  This 
can  best  be  observed  if  the  patient  is  bidden  to  move  his  eye 
sharply  in  different  directions.  (4)  Scars  may  be  seen  on  the 
iris.  These  are  the  result  of  tears  of  the  membrane  during  the 
operation.  In  some  cases  they  are  associated  with  an  irregu- 
larity of  the  pupil,  which  may  be  extreme,  or  with  a  limitation 
or  absence  of  pupillary  movements.  In  other  cases  the  im- 
mobility of  the  pupil,  which  may  be  absolute,  is  associated 
with  (5)  an  atrophic  condition  of  the  inner  free  margin  of  the  iris. 
Such  a  condition  is  only  met  with  in  very  long-standing  cases. 
Transillumination  of  the  eye  will  sometimes  show  up  the 
scars,  or  the  atrophic  condition  just  referred  to,  as  light  spaces 
against  the  rest  of  the  dark  background  of  the  iris.  (6)  A  care- 
ful study  of  the  cornea,  or  of  the  sclera  in  its  neighbourhood, 
will  often  reveal  evidence  of  the  wound  made  by  the  instrument 
during  couching.  In  the  cornea  these  take  the  form  of  small 
nebulae  or  leucomata,  lying  just  within  the  limbus,  and  usually 
in  the  temporal  quadrant.  In  one  case  a  persistent  fistula  was 
met  with,  as  the  result,  presumably,  of  the  bursting  of  a  staphy- 
loma  along  the  original  track  of  a  septic  wound.  Scars  in  the 
sclera  are  much  more  difficult  to  distinguish,  but  they  can 
sometimes  be  detected  by  the  pigmentation  which  overlies 
them ;  such  pigmentation  may  be  due  to  the  inclusion  of  uveal 
pigment  in  the  track  of  the  wound,  as  has  been  shown  by  our 


DIAGNOSIS  79 

pathological  specimens  :  but  this  is  not  the  only  possible 
explanation  of  the  discoloration,  for  in  dark-skinned  races  a 
certain  amount  of  pigmentation  is  not  uncommon  after  injuries 
of  the  conjunctiva.  In  one  of  the  eyes  we  examined,  there 
was  a  filtering  scar  over  a  fistula  which  had  formed  along  the 
track  of  a  scleral  wound.  (7)  We  come  now  to  the  leading 
feature  in  the  diagnosis  of  these  cases — viz.,  the  recognition  of 
the  displaced  cataract  in  its  new  position  within  the  eye.  In 
the  rare  event  of  a  lens  being  dislocated  into  the  anterior 
chamber  and  fixed  there,  its  presence  can  be  easily  recog- 
nised. Again,  in  a  large  number  of  the  cases  which  present 
themselves  in  the  out-patient  room,  the  cataract  can  be  seen 
floating  freely  in  the  vitreous,  and  bobbing  up  and  down  with 
the  movements  of  the  eye.  In  the  case  of  the  milky  Morgagnian 
cataracts,  or  of  those  cortico-nuclear  cataracts  which  present 
a  glistening  and  pearly  -  sectored  appearance,  it  would  be 
difficult  even  for  a  beginner  to  fail  to  see  the  lens,  which  usually 
lies  at  the  lowest  part  of  the  eye.  As  the  patient  sits  in  front 
of  the  surgeon,  the  gleam  of  the  white  cataract  can  be  caught 
each  time  he  looks  downward,  even  though  a  distance  of  two 
or  three  feet  may  separate  him  from  the  observer.  In  the  case 
of  darker  cataracts,  such  as  the  pigmented  nuclear  ones,  fre- 
quently met  with  in  Indian  practice,  a  closer  examination  is 
required. 

The  patient  must  be  brought  nearer  to  the  observer,  and 
facing  a  good  source  of  illumination.  The  surgeon  then 
focusses  the  light  on  the  pupil  by  the  aid  of  a  lens,  bidding  the 
patient  at  the  same  time  to  look  downward.  If  this  fails, 
the  patient  is  instructed  to  bend  his  head  forward,  holding 
the  face  horizontal;  the  surgeon  then  places  one  closed  fist 
on  the  back  of  his  head,  and  gives  a  number  of  sharp  raps  on 
it  with  his  other  fist;  when  this  is  done,  it  is  often  found  that 
the  lens  has  floated  forward  on  to  the  pupil.  If  the  patient's 
head  be  now  quietly  raised,  the  lens  can  be  seen  dropping 
gently  away  from  the  pupil,  which  turns  from  white  or  brown 
(according  to  the  nature  of  the  cataract)  to  black  as  it  does  so. 
The  experiment  can  be  repeated  again  and  again.  Sometimes 
the  lens  falls  away  from  the  pupil  so  quickly  that  the  surgeon 
must  stoop  down  and  look  up  at  the  eye  in  order  to  see  it. 
If  even  after  this  test  he  fails  to  see  the  cataract,  it  is  safe  to 


8o  COUCHING  FOR  CATARACT 

assume  that  it  is  tied  down  in  its  new  position  by  inflammatory 
adhesions  excited  by  the  septic  matter  introduced  at  the  time 
of  operation.  Such  adhesions  may  consist  merely  of  delicate 
fibrils  of  exudate,  which  slightly  increase  the  consistency  of 
the  vitreous  body,  and  so  to  a  small  extent  limit  the  excursions 
of  the  lens;  or  they  may  be  represented  by  firm  and  highly 
organised  fibrous  tissue,  which  mats  the  lens  in  its  new  position, 
and  which  may  be  so  strong  that  even  a  post-mortem  dissection 
would  fail  to  disengage  the  cataract  from  its  adventitious 
position.  This  subject  has  been  dealt  with  much  more  fully 
in  the  chapter  on  pathology.  The  dilatation  of  the  pupil  by  a 
mydriatic  will  often  make  it  quite  easy  to  discover  the  where- 
abouts of  the  cataract,  especially  if  a  strong  light,  whether 
natural  or  artificial,  is  focussed  on  the  eye  by  means  of  a  lens. 
Natural  light  is  preferable  to  artificial  if  possible,  especially 
in  a  country  like  India,  where  powerful  daylight  can  be  counted 
on  during  a.  large  part  of  the  year.  The  advantage  of  the 
white  light  is  especially  marked  when  dealing  with  brown  or 
dark-coloured  cataracts.  An  examination  with  the  ophthal- 
moscope or  with  a  transilluminator  may  sometimes  be  of  value, 
but  in  the  class  of  cases  we  are  now  discussing,  these  are  seldom 
of  much  use,  if  the  examination  just  described  fails  to  reveal 
the  whereabouts  of  the  cataract. 

There  remain  a  few  points  of  interest  which  deserve  mention. 
Though  in  the  great  majority  of  couched  eyes  the  cataract 
lies  in  the  lowest  part  of  the  globe,  it  may  be  found  either  to 
the  inner  or  to  the  outer  side,  or  even  in  the  upper  half  of  the 
eye.  Sometimes  it  flaps  backward  and  forward  with  the  move- 
ments of  the  globe,  swinging  on  a  hinge,  which  evidently  con- 
sists of  the  remaining  fibres  of  the  suspensory  ligament,  and 
which  may  be  situate  in  any  possible  direction,  though  most 
often  it  lies  below.  It  will  be  readily  understood  that  if  this 
hinge  is  situate  below,  or  to  the  inner  or  outer  sides,  the  lens 
will  flap  away  from  the  pupil  downward,  or  to  the  hinged  side, 
as  the  case  may  be.  It  is  not  inconceivable  that,  in  repeatedly 
doing  so,  it  may  inflict  some  measure  of  injury  on  the  neigh- 
bouring part  of  the  ciliary  body  and  retina,  and  may  thus  ex- 
cite a  local  inflammation  which  will  tend  in  time  to  tie  the 
cataract  permanently  in  the  new  position  towards  which  it 
flaps,  away  from  the  pupil.  In  the  event  of  the  hinge  being  in 


DIAGNOSIS  81 

one  of  the  three  directions  now  under  discussion,  the  cataract 
will  tend  to  fall  forward  on  to  the  pupil  only  when  the  patient 
stoops  forward,  so  as  to  bring  his  face  into  the  horizontal  plane. 
When  the  hinge  is  situate  above,  the  latter  is  one  of  the  few 
positions  of  the  face  in  which  the  pupil  clears  itself  in  ordinary 
cases;  but  one  meets  with  instances  in  which,  despite  the 
hinge  being  above,  the  pupil  remains  clear  except  when  the 
face  is  horizontal,  the  lens  lying  most  of  the  time  in  the  upper 
segment  of  the  eye.  There  is  another  factor,  and  probably  a 
more  frequent  one,  than  that  of  the  local  injury  inflicted  by 
the  lens  during  its  movement,  which  tends  to  tether  it  in  situ. 
This  is  the  increasing  consistence  of  the  vitreous,  due  to  the 
deposit  within  it  of  inflammatory  matter,  a  point  which  has 
already  been  alluded  to. 

Our  next  consideration  is  that  of  the  cases  in  which  the 
cataract  still  lies  behind  the  pupil.  It  then  seldom,  if  ever, 
is  in  absolutely  normal  position,  and  it  very  frequently  is  found 
to  have  been  moved  bodily  downwards  or  to  one  side,  or  ob- 
liquely. Again,  but  more  rarely,  it  may  be  tilted  backward 
at  an  angle  with  the  plane  of  its  normal  position.  In  a  great 
number  of  cases  the  history  will  help  one,  and,  even  when 
the  patient  denies  couching,  he  will  very  often  admit  to  having 
had  "  medicine  applied  to  his  eye  by  a  native  practitioner." 
Should  no  such  evidence  be  forthcoming,  there  may  still  re- 
main that  of  the  lesions  to  the  cornea,  the  sclera,  or  the  iris, 
to  which  attention  has  already  been  directed  in  the  previous 
section. 

From  these  cases  we  pass  on  to  consider  those  in  which  the 
lens  cannot  be  seen  at  all,  owing  to  the  occlusion  of  the  pupil. 
Here  our  difficulties  are  greater  still,  and,  if  the  history  fails 
us,  we  must  fall  back  on  a  careful  search  for  signs  of  wound 
scars  in  the  cornea  or  sclera,  or  of  tears  in  the  iris.  A  point 
which  is  always  suggestive  is  the  existence  of  a  cataract  in 
the  opposite  eye.  In  such  cases  as  these,  the  contents  of  the 
chamber  may  be  found  to  consist  of  pus  or  of  blood. 

Our  next  group  is  a  still  more  difficult  one,  for  in  it  no  fundus 
reflex  can  be  obtained.  It  embraces  a  number  of  conditions 
which  may  be  shortly  dealt  with  in  turn :  (i)  Those  in  which 
the  vitreous  body  has  been  converted  into  a  more  or  less  highly 
organised  inflammatory  exudate,  which  is  impenetrable  to 

6 


8s        COUCHING  FOR  CATARACT 

the  light  of  the  ophthalmoscope.  (2)  Those  in  which  this 
vitreous  exudate  has  contracted  inflammatory  adhesions  to 
the  retina,  and  by  its  shrinkage  has  determined  the  total  de- 
tachment of  that  membrane.  (3)  Those  in  which  the  vitreous 
chamber  has  become  filled  with  blood.  It  is  obvious  that  in 
all  such  cases  our  main  dependence  must  be  upon  the  history, 
though  the  other  indications  already  outlined  may  help  us 
in  some  of  them. 

Lastly  there  are  the  cases  in  which  the  eye  is  undergoing 
shrinkage,  and  those  in  which  phthisis  bulbi  is  following  pan- 
ophthalmitis.  The  history  of  the  signs  and  symptoms  of 
severe  iridocyclitis  or  of  suppuration  will,  in  India  at  least, 
always  excite  a  suspicion  of  couching  having  been  performed, 
unless  the  patient  has  a  definite  story  to  tell  of  some  other  form 
of  injury.  Strangely  enough,  the  inventive  faculty  of  the 
Indian  patient  does  not  rise  to  the  height  of  vamping  a  narrative 
of  the  kind.  If  he  has  had  an  injury,  he  tells  of  it  readily. 
If  he  has  been  couched,  he  stolidly  denies  that  anything 
occurred  to  cause  his  trouble,  which  he  states  "  simply  came 
of  itself." 

It  will  be  observed  that  in  the  preceding  remarks  we  have 
dealt  with  two  of  the  problems  which  confront  us  in  diagnosis, 
for  the  simple  reason  that  it  is  very  difficult  to  separate  them ; 
to  do  so  would  mean  needless  repetition.  The  discovery 
of  the  new  position  of  the  lens,  and  of  the  degree  of  fixation, 
if  any,  it  has  undergone,  can  hardly  be  divorced  from  the  ques- 
tion of  whether  a  couching  has  or  has  not  been  performed. 
Our  third  problem  was  to  decide  whether  it  is  advisable  to 
operate  in  any  cases,  and  if  so,  in  which.  The  Baron  de  Wenzel, 
in  his  treatise  on  cataract,*  records  two  cases  in  which  his 
father  successfully  extracted  couched  lenses.  A  number  of 
Anglo-Indian  surgeons  have  had  similar  experiences,  but  most 
of  them  are  reluctant  to  interfere  with  these  cases  oftener  than 
they  can  help,  because,  should  the  operation  fail,  it  is  extremely 
likely  that  they  will  unjustly  incur  the  odium  for  the  loss  of 
the  patient's  vision.  On  this  subject  Maynard  wrote  (Ophthal- 
mic Review,  April,  1903) :  "  It  may  be  justifiable  to  attempt 
the  removal  of  a  recently  couched  lens.  If  not  recent,  and  more 
especially  if  the  lens  is  fixed,  it  is  wiser  to  leave  it  alone,  even 

*  Translation  by  James  Ware,  surgeon,  F.R.S.;  London,  1812, 


DIAGNOSIS  83 

if  the  sight  is  failing."  To  the  writer's  mind,  the  one  crying 
indication  for  removal  of  a  couched  lens  is  that  it  flaps  across 
and  obstructs  the  pupil.  He  agrees  strongly  with  Maynard,  that 
if  the  lens  is  fixed  it  is  better  left  alone;  but  he  is  doubtful 
whether  the  time  element  is  of  very  great  importance,  in  com- 
parison with  the  mobility  of  the  cataract  ;  for  a  study  of 
the  fifty-four  globes  already  dealt  with  has  shown  him  that 
the  fixation  or  otherwise  of  the  lens  is  a  question  of  the  amount 
of  septic  action  set  up  by  the  operation.  If  this  is  small, 
the  lens  may  continue  mobile,  even  for  a  very  long  period; 
if  it  is  more  severe,  the  latter  will  soon  be  tethered.  Dealing 
with  this  subject  five  years  ago  (Proc.  of  S.  Indian  Branch  of 
B.M.A.,  March  13,  1912),  the  author  wrote  as  follows: 

'  We  are  extremely  reluctant  in  Madras  to  undertake 
further  operative  procedures  on  an  eye  in  which  couching  has 
been  performed.  Removal  of  a  lens  dislocated  into  the  pos- 
terior chamber  obviously  means  a  wide  opening  up  of  the 
vitreous;  and  even  if  the  immediate  result  appears  good, 
there  is  little  guarantee  that  the  benefit  will  continue.  Of 
eighteen  cases  in  which  the  lens  was  removed,  twelve  obtained 
better  vision  at  the  time,  four  remained  in  statu  quo,  and  two 
were  rendered  worse.  I  cannot  but  think  that  these  statistics 
would  suffer  if  the  cases  were  followed  for  some  years.  On 
five  occasions  we  undertook  the  laceration  of  an  after-cataract 
which  blocked  the  line  of  sight  after  couching.  In  two  cases 
there  was  considerable  benefit,  whilst  in  three  vision  remained 
in  statu  quo  antea.  In  four  cases  an  iridectomy  was  performed 
for  optical  purposes.  In  two  vision  improved  slightly,  whilst 
in  the  two  others  it  remained  as  before. 

"  Personally  I  have  a  strong  and  growing  objection  to 
undertake  any  operative  procedure  on  a  couched  eye.  Firstly, 
there  is  the  risk  of  lighting  up  a  septic  explosion,  for  which  the 
real  responsibility  lies  with  the  coucher's  original  operation; 
and,  secondly,  there  is  the  danger  of  being  saddled  with  the 
discredit  which  is  justly  due  to  another  man's  failure." 

Reviewing  these  paragraphs  in  the  light  of  the  much  better 
knowledge  of  the  pathology  of  couching  which  we  possess 
to-day,  he  would  urge  that  only  freely  movable  cataracts  should 
be  touched,  since  want  of  mobility  is  associated  with  profound 
changes  in  the  vitreous  due  to  septic  action.  The  object  that 


84        COUCHING  FOR  CATARACT 

a  surgeon  sets  before  him,  work  where  he  may,  is  ever  the  same 
'  The  greatest  good  of  the  greatest  number."  Failure  in 
such  cases  as  these  may  play  into  the  hands  of  the  coucher, 
and  enable  him  to  extend  his  sphere  of  influence  at  the  expense 
of  the  beneficent  work  of  the  Western  hospitals.  The  problem 
in  India  is  a  difficult  one,  in  which  surgical  considerations 
do  not  stand  alone,  but  are  interwoven  with  social,  moral,  and 
even  political  questions.  Each  surgeon  must  decide  for  him- 
self what  line  he  will  take,  and  follow  it  fearlessly. 

In  this   connection,  Major   Kirkpatrick's  experience  *  in 
Madras   is    of    considerable    value,   for   he    has    removed   a 
number    of   couched    lenses,  and  has  been  "  struck   by  the 
rarity  of  vitreous  escape,  even  after  fairly  extensive  investiga 
tion  with  a  spoon,"   during  this  operation.     He  adds:   "  I 
have  noticed  that  the  vitreous  body  becomes  shrunken  and 
extraordinarily  tough,  so  much  so  that,  when  an  eye  is  excised 
(either  for  glaucoma  or  for  iridocyclitis  following  Mahomedan 
operation),  the  whole  globe  can  be  held  up  by  a  strabismus 
hook  transfixing  the  vitreous,  though  the  latter  appears  per- 
fectly clear.     The  vitreous  undoubtedly  does  undergo  shrink- 
age, and  leaves  a  large  space,  which  is  occupied  by  aqueous." 
It  is  plain  that  he  is  referring  here  to  cases  in  which  the  vitreous 
body  has  undergone  some  measure  of  inflammatory  organisa- 
tion, which  might  be  expected  to  limit  the  mobility  of  the  lens, 
and  it  will  be  of  great  interest  to  learn  whether  the  conclusions 
of  so  reliable  and  experienced  an  observer  ultimately  coincide 
with  the  author's,  that  interference  should  be  confined  to  those 
cases  in  which  the  movements  of  the  cataract  within  the 
vitreous  body  are  noted  to  be  free.     Once  again,  let  it  be 
emphasised  that  there  are  two  distinct  questions  at  issue — one 
the  benefit  of  the  individual  patient,  and  the  other  the  good 
name  of  Western  surgery.     Each  man  must  be  guided  accord- 
ing to  the  dictates  of  his  own  personality  and  of  his  environ- 
ment. 

*   Personal  communication. 


CHAPTER  VII 
CLINICAL 

THERE  are,  in  connection  with  cases  of  couched  cataract, 
some  points  of  clinical  interest  which  will  repay  closer  attention. 
These  will  now  be  dealt  with  in  turn. 

Pain. — The  pain  which  follows  the  operation  of  couching 
has  attracted  the  attention  of  surgeons  from  very  early  times, 
and  there  has  been  much  speculation  as  to  its  cause.     When, 
after  Daviel's  discovery,  extraction  came  into  serious  competi- 
tion with  the  older  operation,  surgeons  discussed  at  much  length 
the  relative  merit  of  the  two  procedures,  and  it  was  strongly 
urged  by  the  extractionists  that  their  operation  gave  rise  to 
less  pain  than  that  of  couching.     The  subject  is  a  very  difficult 
one,  for  no  surgeon,  who  has  had  a  large  cataract  practice, 
can  fail  to  have  been  struck  by  the  extraordinary  difference 
in  the  statements  of  patients  as  to  the  amount  of  suffering 
they  have  endured  during  the  first  twenty-four  hours  after 
the  removal  of  a  lens.     The  majority  of  them  confess  to  a 
good  deal  of  pain ;  this  comes  on  as  the  effect  of  the  anaesthetic 
wears  off,  reaches  a  maximum,  and  then  slowly  dies  away, 
leaving  them  at  the  end  of  twelve  hours,  and  often  even  at 
the  end  of  six  hours,  comparatively  comfortable.     Occasionally, 
but  rarely,  the  report  is  that  the  pain  has  been  negligible 
throughout.     On  the  other  hand,  a  bitter  complaint  of  very 
severe  pain  is  sometimes  encountered;  fortunately  such  an 
occurrence  is  infrequent.     In  the  case  sheets  on  which  the 
writer's  780  cases  were  taken,  a  special  heading  was  provided 
for  notes  on  the  pain  inflicted  at  or  after  operation.     A  strik- 
ing feature  of  the  replies  given  was  the  extraordinary  differ- 
ence between  them;  this  is  the  more  astonishing  because  in  a 
large  number  of  the  operations  it  is  probable  that  no  anaesthetic 
of  any  kind  was  used,  and  yet  it  was  by  no  means  uncommon 
to  meet  with  patients,  who  made  little  or  nothing  of  the  pain 

85 


86  COUCHING  FOR  CATARACT 

either  at  the  operation  or  after  it.  On  the  other  hand,  some 
complained  of  terrible  suffering,  commencing  as  soon  as  the 
needle  was  inserted,  and  lasting  for  long  periods  thereafter. 
The  majority  admitted  to  some  pain,  but  neither  belittled 
nor  exaggerated  it.  It  will  thus  be  seen  that,  so  far  as  pain  is 
concerned,  the  experiences  of  the  coucher  and  of  the  extractor 
are  much  alike;  it  is  unfair  to  judge  either  operation  on  excep- 
tional cases. 

Looking  at  the  subject  from  the  anatomical  side,  the  writer 
is  bound  to  confess  that  an  argument  a  priori  would  have  led 
him  to  expect  extraction  to  have  been  by  far  the  more  painful 
of  the  two  procedures,  both  at  the  time  and  during  the  early 
hours  of  convalescence,  although  much  has  been  made  by  early 
writers  of  injury  to  the  retina  and  to  the  sensitive  ciliary 
body,  and  of  the  extensive  damage  done  by  the  needle  during 
a  couching.  We  know,  however,  that  injury  to  the  retina 
does  not  produce  pain;  and  we  are  also  well  aware  of  the  ex- 
treme susceptibility  of  the  cornea  to  pain.  Surely  the  extent 
of  damage  inflicted  on  sensitive  structures  is,  as  a  rule,  much 
greater  in  an  extraction  than  it  is  in  a  couching.  How  then 
are  we  to  explain  the  dread  with  which  surgeons,  in  the  days 
of  couching,  looked  forward  to  the  suffering  and  vomiting 
which  sometimes  followed  the  operation  ?  In  answer  to  this 
question  the  following  suggestions  are  put  forward.  The  pain 
of  the  first  twelve  hours  is  to  be  sharply  differentiated  from 
that  which  begins  on  the  second  or  third  day,  always  remember- 
ing, however,  that,  though  the  causes  are  different,  the  one 
may  run  into  the  other.  The  early  pain  may  be  ascribed 
(i)  to  injury  to  the  nerves  of  the  ciliary  body  and  iris,  especially 
when  the  laceration  of  those  structures  is  considerable,  as  our 
clinical  experience  and  our  specimens  alike  show  it  sometimes 
is;  (2)  to  haemorrhage  from  the  vessels  of  the  ciliary  body, 
the  iris,  the  choroid  or  the  retina  :  such  haemorrhage  may 
produce  pain  in  two  ways — (a)  by  dissecting  up  sensitive 
structures,  and  (b)  by  increasing  the  tension  of  the  eye;  and 
(3)  to  the  rapid  production  of  early  glaucoma.  There  are 
several  ways  in  which  we  may  conceive  that  such  a  glaucoma 
might  be  produced.  We  have  already  mentioned  the  possi- 
bility of  haemorrhage.  Then  we  have  to  remember  that, 
in  the  course  of  this  operation,  the  anterior  portion  of  the 


CLINICAL  87 

vitreous  body  is  often  extensively  interfered  with.  It  is 
conceivable  that  a  forward  movement  of  this  part  may  close 
the  angle  of  the  chamber,  and  so  interfere  with  excretion. 
Again,  when  the  lens  is  forced  back  on  the  vitreous  body, 
and  the  anterior  hyaloid  layer  remains  unbroken,  we  sometimes 
find  it  acting  as  a  wedge,  pushing  the  base  of  the  iris  forward, 
and  thrusting  the  hyaloid  membrane  backward.  The  latter 
action  must  press  on  the  vitreous  body,  and  so  make  it  bulge 
at  other  parts  of  the  circumference  of  the  eye,  thus  tending  to 
close  the  angle  of  filtration  over  such  areas.  It  is  obvious  that 
the  pressure  of  the  lens  on  the  iris  base  will  directly  close  the 
sinus  locally  to  a  greater  or  less  degree.  A  point  that  we  must 
never  lose  sight  of  is  that  the  very  great  majority  of  these 
patients  are  in  the  glaucoma  period  of  life,  and  with  a  certain 
number  of  them  very  little  alteration  of  the  status  quo  is  re- 
quired to  precipitate  an  attack  of  pathological  high  tension. 
If  we  take  all  these  factors  into  account,  and  especially  if  we 
bear  in  mind  the  great  variability  that  different  patients 
present  in  their  sensibility  to  pain,  we  shall  have  little  difficulty 
in  understanding  that  couching  may  sometimes  be  followed 
within  the  first  few  hours  by  great  suffering  attended  with 
vomiting. 

\Yhen  we  come  to  discuss  the  later  pain,  all  difficulty 
vanishes.  The  frequency  with  which  iridocyclitis  and  glau- 
coma dog  the  footsteps  of  couching  in  India,  explains  at  once 
the  bitter  and  oft-repeated  history  of  pain  coming  on  within 
the  first  two  or  three  days,  and  lasting  for  months  or  even 
for  years. 

Some  Rare  Accidents  following  Couching. — In  a  large  series 
of  cases  such  as  we  now  have  under  review,  it  was  to  be  ex- 
pected that  some  unusual  incidents  would  be  met  with.  A 
few  of  these  will  be  dealt  with. 

i.  The  Dislocation  of  the  Lens  into  the  Anterior  Chamber. — 
This  accident  was  known  to  the  early  writers.  It  may  occur 
either  at  the  time  of  operation  or  subsequently.  In  the  former 
case  the  nucleus  alone  may  be  dislocated,  or  the  whole  lens  may 
be  driven  forward  in  its  capsule.  It  may  lie  loose  and  freely 
movable  in  the  chamber,  or  may  become  mechanically  impacted 
there,  or,  lastly,  may  be  firmly  fixed  in  situ  as  a  result  of  in- 
flammatory action.  In  the  cases  of  late  dislocation  it  is  usually 


88         COUCHING  FOR  CATARACT 

the  nucleus  alone  that  passes  forward,  the  cortex  having 
either  become  absorbed  or  the  cataract  having  originally  been 
of  the  Morgagnian  variety.  Such  are  the  cases  which  give 
rise  to  the  interesting  clinical  phenomenon  of  a  nucleus  which 
passes  backwards  and  forwards  between  the  two  chambers. 
In  some  cases  alterations  in  the  position  of  the  patient's  head 
suffice  to  make  the  lens  travel  in  one  direction  or  the  other. 

2.  The  Dislocation  of  the  Lens  between  the  Ciliary  Body  and 
the  Solera  through  the  ruptured  pectinate  ligament  occurred  in 
one  case.     Such  an  accident  must  be  very  rare  under  any 
possible  conditions  of  eye  injury.     J.  B.  Lawford,  in  the  Re- 
ports of  the   Royal  London  Ophthalmic  Hospital   (1886-87, 
p.  334),  recorded  a  similar  happening  which  followed  a  blov\ 
on  the  eye  by  a  clasp-knife  thrown  at  a  woman.     Nettleship 
(Ophth.  Soc.  Trans.,  vol.  i.)  also  published  a  case  in  which 
an  opaque  lens  disappeared  into  a  pouch  between  the  choroid 
and  sclera  when  the  patient  lay  down,  and  reappeared  in  the 
anterior  chamber  when  he  stood  up.     The  condition  followed 
a  blow  on  the  eye  inflicted  some  years  previously. 

3.  Dislocation  o/  the  Lens  behind  the  Retina. — This  accident 
was  known  to  the   early  writers,   and  Mackenzie  expressly 
gives  the  warning  that,  if  in  effecting  depression  "  the  handle 
of  the  needle  is  raised  much  higher  than  the  horizontal  position, 
the  cataract  is  apt  to  be  pressed  through  the  retina,  and  vision 
extinguished."     Daviel  had  met  with  the  same  condition  in 
eyes  which  he  dissected  after  death,  and  which  had  been 
couched  by  other  surgeons.     We,  too,  encountered  it  twice  in 
our  pathological  material.     In  one  eye  the  retina  had  been 
torn  away  from  the  ora  serrata,  and  the  lens  pushed  behind 
it ;  in  the  other,  an  extensive  hole  had  been  torn  in  the  retina, 
and  through  this  the  cataract  had  been  thrust.    In  both,  the 
cataracts  were  Morgagnian  and  had  been  dislocated  in  their 
capsules,  and  in  both,  the  retinae  had  undergone  total  detach- 
ment, in  this  latter  respect  testifying  to  the  value  of  Mackenzie's 
warning. 

A  Comparison  of  Depression  and  Reclination.— There  can 
be  no  question  that  the  operation  of  reclination  breaks  up  the 
vitreous  body  to  a  considerably  greater  extent  than  mere 
depression  of  the  cataract  does.  On  the  other  hand,  the 
claim  is  made  that  after  its  performance  the  lens  is  much  less 


CLINICAL  89 

likely  to  undergo  reascension;  indeed,  it  was  for  this  reason 
that  Willburg  introduced  the  method;  and,  if  we  may  judge 
from  the  evidence  of  later  writers,  he  was  justified  by  results. 
So  far  as  the  Indian  coucher  is  concerned,  it  seems  a  little 
doubtful  whether  he  has  any  clear  conception  of  the  differ- 
ence between  the  two  procedures;  indeed,  so  long  as  he  gets 
the  lens  out  of  the  way  of  the  pupil,  it  is  probable  that  he 
neither  knows  nor  cares  which  method  he  has  succeeded  in 
adopting,  though  he  probably  much  more  often  reclines 
than  depresses.  This  may  be  explained  by  the  experience  of 
a  number  of  European  surgeons,  that  it  is  more  easy  to  effect 
reclination  than  depression.  An  interesting  point  is  that 
in  quite  a  number  of  our  pathological  specimens  the  lens  lay 
in  front  of  the  anterior  hyaloid  membrane,  and  therefore 
outside  the  vitreous  body ;  most  of  these  were  cases  of  depres- 
sion, but  in  a  few  of  them  the  lens  is  turned  backwards  at  an 
angle  with  its  ordinary  plane,  clearly  showing  that  a  partial 
reclination  had  been  effected. 

Reascension  of  Couched  Cataract. — This  subject  has  been 
partly  dealt  with  in  the  preceding  paragraphs.  Naturally, 
it  was  a  topic  which  attracted  a  good  deal  of  attention  from 
the  early  writers,  who  commented  on  its  relative  frequency 
immediately  after  the  operation,  and  gave  elaborate  instruc- 
tions to  prevent  its  occurrence.  Some  of  them  went  so  far  as 
to  suggest  the  frequent  repetition  of  the  operation,  if  necessary. 
In  their  experience  it  would  appear  that,  if  reascension  failed 
to  occur  within  the  first  fortnight,  the  prospect  of  the  lens 
remaining  down  was  good.  Nevertheless,  they  were  familiar 
with  the  fact  that,  even  after  years  of  a  happy  result,  the 
cataract  might  suddenly  be  found  to  have  returned  to  its  old 
position  opposite  the  pupil.  In  some  cases  this  misfortune 
followed  a  blow  or  fall  on  the  head,  or  a  severe  jar  of  the  whole 
body.  Similar  stories  may  be  heard  in  an  Indian  out-patient 
room  to-day.  This  is  a  point  which  must  be  taken  well  into 
consideration  by  any  who  think  fit  to  resort  to  couching  in 
selected  cases. 

A  Comparison  of  the  Corneal  and  Scleral  Routes  for  Opera- 
tion.— It  has  been  already  shown  that  the  Indian  operators 
of  the  present  day  vary  in  their  technique,  some  attacking 
the  lens  from  in  front  through  the  cornea,  and  others  from 


go  COUCHING  FOR  CATARACT 

behind  through  the  sclera.  It  is  interesting  to  note  that  there 
is  a  similar  difference  in  practice  amongst  those  of  the  modern 
surgeons  who  have  adopted  couching  in  special  cases.  There 
can,  however,  be  no  doubt  that  the  weight  of  opinion  among 
the  old  writers  was  all  in  favour  of  the  posterior  operation ;  and 
Mackenzie,  whose  practical  experience  was,  we  may  hope, 
vastly  greater  than  that  of  any  modern  surgeon,  summed  up 
the  position  in  these  words:  "  In  this  way  (i.e.,  through  the 
cornea)  neither  operation  (depression  or  reclination)  can  be 
satisfactorily  performed."  We  may  close  this  subject  with 
another  word  of  warning  to  any  who  are  inclined  to  favour 
the  couching  of  lenses  in  selected  cases.  From  the  time  of 
Celsus  onwards,  surgeons  who  have  had  large  experience  in 
couching  have  warned  their  disciples  that  it  is  an  operation 
much  more  easy  to  undertake  than  to  carry  to  a  successful 
technical  issue,  and  have  cautioned  them  against  venturing 
on  it  until  they  have  seen  it  performed  many  times  at  the 
hands  of  an  expert.  One  cannot  conclude  better  than  by  a 
quotation  from  the  writings  of  Lieut'.-Colonel  Henry  Smith, 
who  has  had  very  large  opportunities  of  observing  the  results 
of  cataract  couching.  He  is  known  to  be  a  very  skilful  operator, 
and  one,  therefore,  who  is  little  likely  to  exaggerate  the  diffi- 
culties of  any  ophthalmic  procedure,  yet  he  writes:  "  It  is  no 
easy  matter  to  completely  dislocate  the  lens,  and,  in  my  ob- 
servation, the  partial  dislocation  is  more  frequent  than  the  com- 
plete in  the  hands  of  adepts  of  the  art." 

The  Dislocation  of  Morgagnian  Cataracts. — A  curious 
error  is  to  be  found  pervading  many  of  the  early  writings  on 
couching — viz.,  that  a  Morgagnian  cataract  could  not  be 
couched  in  its  capsule.  Our  hospital  experience  in  India 
proved  that  this  idea  was  erroneous,  and  the  examination  of 
our  pathological  specimens  has  shown  the  correctness  of  our 
clinical  deductions.  The  Morgagnian  lens  may  be  dislocated 
forward  into  the  anterior  chamber,  backward  into  the  vitreous, 
and  even  through  the  coats  of  the  retina,  without  rupture  of  its 
capsule.  This  is  far  from  being  a  surprise  to  any  surgeon 
who  has  operated  on  a  number  of  these  cases,  for  the  Morgag- 
nian capsule  is  usually  very  much  tougher  than  that  of  any 
other  form  of  cataract.  It  has  already  been  mentioned  that, 
if  the  capsule  bursts,  the  nucleus  may  escape,  and  may  then 


CLINICAL  91 

sometimes  be  found  either  floating  freely  in  one  of  the  chambers 
of  the  eye,  or  fixed  in  one  position  by  inflammatory  adhesions, 
or,  still  more  rarely,  passing  from  chamber  to  chamber  at  in- 
tervals. The  writer  has  observed  that  in  some  cases  the  escape 
of  Morgagnian  fluid  into  an  eye  appears  to  cause  great  irrita- 
tion. The  same  fact  has  been  observed  by  some  of  the  early 
writers  on  couching. 


INDEX 


Abu  el  Kasim,  2,  4 
Accidental  injuries  during  couch- 
ing, 46 
Advocacy  (modified)  of  couching, 

10,    II,    12 

.*Egineta,  Paulus,  3 

Age  of  patient,  usual  in  couching, 

-27 

Alberto  tti,  10 
Alexandria,   ophthalmic  surgeons 

in,  i 

Anaesthesia  during  couching,  15,  21 
Anatomical    examination    of 
couched   eyes,    by   Collins,    1 1 ; 
by  Hudson,  1 1 ;  by  Kirkpatrick, 
ii ;  by  Parsons,  10 
Anterior  chamber,  55 

albuminous  exudates  in, 

56 

blood  in,  56 
lens  matter  in,  56 
pus  in,  56 

scantiness  of  contents,  55 
vitreous  substance  in,  56 
Anterior  operation,  14 
Antiquity  of  couching,  i 
Antillus,  7 

Apology  for  the  coucher,  23 
Avicenna,  2,  3,  4 

B 

Bartisch,  5 

Basso,  ii 

Bell,  Benjamin,  7 

Benvenuto,  4 

Bland-Sutton,  Sir  John,  i 

Brisseau,  Pierre,  7 


Capsulo-corneal  synechia,  46 
Cataracts,    entangled   in   vitreous 

exudate,  39,  81 
fixed  in  vitreous  chamber,  40, 

80 

floating  freely  in  vitreous,  39 
matted  in  inflammatory  tis- 
sue, 43 
peculiarities  of,  in  India,  32 


Causes  of  failure  after  couching,  28 
Celsus,  i,  2,  3,  7,  90 
Charlatanism,  6,  7,  20 
Chemotaxis,  61,  63 
Choroid,  73 

changes  in,  due  to  hypotony, 

73 

detachments  of,  73 
Choroidal   vessels   unusually   dis- 
tinct, 74 

Collins,  E.  T.,  n,  12,  73 
Comparison     of    depression     and 

reclination,  88 
of   pain   after   couching   and 

after  extraction,  86 
of  scleral  and  corneal  routes 

for  operation,  89 
Condemnation  of  couching,  n,  22, 

26,  77 

Copper  probe,  16,  17,  51 
Cornea,  fistula  of,  46,  78 

scars  in,  16,  46,  78 
Coucher,  descriptive  titles  of,  19 
Coucher's  methods,  20,  33 
Cusson,  7 
Cyanopsia,  32 

D 

Dark  Ages,  couching  in,  6,  20 
Daviel's  extraction,  7 
Delayed  iridocyclitis,  28 
Demonstration   of  couched   cata- 
ract, method  of,  79 
Depression  of  cataract,  8,  88 
Diagnosis  of  couching  having  been 

performed,  77 
Difficulties    in    deciding    surgical 

questions  in  India,  84 
Difficulty  of  couching,  1 1 ,  90 
Dislocation     of     cataract,     back- 
ward, 39 

behind  retina,  45,  88 
between  ciliary  body  and 

sclera,  88 
forward,  36,  87 
in  front  of  anterior  hya- 
loid membrane,  44 
partial,  81 

Drake-Brockman,  E.  F.,  22 
Drake-Brockman,  H.  E.,  9,  22 


92 


INDEX 


93 


Ekambaram,   10,    n,   16,   17,   24, 

26,  49 

Extraction  of  cataract,  7 
Extraction   of   couched   cataract, 

61,  77,  82,  83,  84 


Fees  of  couchers,  22 
Fixation  of  lens,  degree  of,  82 
Fowl's  blood,  use  of,  by  couchers 

18,  20 
Fundus  reflex  absent,  81 


Galen,  3 

Glaucoma,  28,  29,  74 

after  couching,  86 

causes  of,  after  couching,  75, 
76 

frequency  of,   after  couching, 

74.  75 

Government  servants  as  couchers, 
22 

H 

Habits  of  couchers,  19 

Haemorrhage  after  couching,  67 

Haly  Abbas,  2 

Hay,  William,  7 

Headquarters  of  couchers,  19 

Hindu  couchers,  19 

Hirschberg,  9 

Histories  of  Indian  patients,  un- 
reliable, 77,  82 

Hudson,  A.  C.,  n 

Hyphsema,  56 

Hypopyon,  56 

Hypotony,  effect  of,  on  uveal 
tract,  73 


Imperfect  dislocation  of  cataract, 

28,  29 
Incision,  variation   of  site  of,   in 

couching,  49 
Indian    Medical    Service    Officers 

and  couching,  9 

Instruments  for  couching,  4,  16,  20 
Invention  of  couching,  first,  2 
Iridocyclitis,  25,  28 
Iris,  atrophy  of,  78 

flat  plane  of,  in  couched  eye, 

77 

scars  in,  16,  78 
tremulous,  78 
Iris  bombe,  55 


Jesu  Haly ,£2 


K 


Kirkpatrick,  H.,  n,  61, 
Knife,  guarded,  16 


Lens,  calcification  of,  55 
Listerism,  influence  of,  on  couch- 
ing, 9 

M 

Mackenzie,  7,  90 

Magic,  element  of,  in  couching,  24 

Mahomedan  couchers,  19,  21 

Maynard,  F.  P.,  n 

Membrane,  dried  pieces  of,  used 
by  couchers,  20 

Metabolic  changes  in  develop- 
ment of  cataract,  33 

Miracles,  early  Christian,  18 

Mistakes  in  diagnosis,   couchers', 

23,  29,  3° 
Morgagnian  cataracts,  27,  90 

O 

Ophthalmoscopy  of  couched  eyes, 

31,  80 

Optic  atrophy,  28,  29 
Optic  neuritis,  30,  63 


Pain  during  couching,  15 

following  couching,  85,  87 
causes  of,  86 

Panophthalmitis,  25,  52,  82 

Parsons,  J.  H.,  10 

Pathological    material    available, 

35 

Philoxenes,  I 

Phthisis  bulbi,  82 

Position     of     couched     cataract, 

recognition  of,  77,  79,  80,  82 
Posterior  operation,  16 
Pott,  Percival,  7 
Power,  Henry,  10 
Punjabi  couchers,  21 
Pupil,  blackness   of,    in    couched 

cataract,  77 
occlusion  of,  81 


Q 


Quartillera,  n 


94 


INDEX 


R 

Razes,  2 

Reascension  of  couched  cataract, 

89 

Reclination  of  cataract,  7,  8,  88 
Reluctance    to    remove    couched 

lenses,  77 

Removal  of  couched  lens,  61 
Results  of  couching,  25,  26,  27 
Retina,  cysts  of,  65,  70,  73 
dots  on,  68 

dots  on,  frequency  of,  68 
dots  on,  pathology  of,  69 
Retinal  changes  ascribed  to  couch- 
ing, 30 

Retinal  detachment,  28,  29,  64 
causes  of,  64,  65,  66 
due    to    operative    trau- 

matism,  68 
stick-like,  65 

Retinal   pigment,    changes   found 

in,  after  cataract-extraction,  32 

Retinal  pigment,  changes  in,  found 

in  couched  eyes,  31,  32 
Retino-corneal  synechia,  46 


Sandalwood  paste,  17 

Scarpa,  7 

Scarpa's  needle,  8 

Sclera,  scars  of,  49,  78 

Scleral  fistula,  50 

Smith,  H.,  n,  22,  26 

Social  status  of  couchers,  22 

Sprengel,  i 

Statistics  of  couching,  author's,  1 1, 

22,  25,  26 

Kirkpatrick's,  n,  25 
Maynard's,  10,  22 

Straub  on  experimental  hyalitis, 
61 

Subretinal  exudate,  67 

Suction  of  cataract,  7 

Suppression  of  couching,  34 

Sympathetic  ophthalmia,  29,  55 


Tabri,  2 

Technique    of    couching,    Abu    el 
Kasim,  4 

Avicenna,  4 

Bartisch,  5 

Benvenuto,  4 

Brisseau,  7 

Celsus,  2,  3 

Indian  operators,  10,  14, 
16,  25 

Mackenzie,  7 

Thorn  used  in  couching,  14 
Tobit,  recovery  of  sight  of,  i 
Transillumination  of  couched  eyes, 
80 

U 

Uveal  coat,  calcification  of,  55 
Uveal  tract,  injuries  of,  50 
Uveitis,  plastic,  52 
Uveitis,  proliferative,  55 

V 

Visual  results  after  couching,  27 
Visual    results    of    couching    and 

extraction  compared,  28 
Visual  tests  employed  by  couchers, 

16 

Vitreous  body,  infiltration  of,  59 
Vitreous  chamber,  56 

cone  of  exudate  in,  30,  43 
cone      of      exudate      in, 
altered  artificially,  60 
cone  of  exudate  definite- 
ly pathological,  60 
filmy  exudate  in,  62 
Vitreous  exudate,  fibrous  organi- 
sation of,  59,  64 
Vitreous  opacities,  28 

W 

Ware,  James,  7 
Willburg,  7 


H.    K.    LEWIS   &   CO.    LTD.,   GOWKR   STREET,    LONDON,    W.C. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


8IOMED  LIB. 

MAR  2  3  RECD 


Form  L9-Series  4939 


3  1158  00060  5716 


A     000  387  044     1 


